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Dr. Thos. Phillips, Austin, Minn., says: " I have used it in the 
insomnia of phthisis pulmonalis, with immediate good." 

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it in phthisis and debility, physical or nervous, and have been pleased 
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X 



SLEEP, 

INSOMNIA, AND HYPNOTICS. 



/by 



E. P.'HURD, M. D., 



Member of the Massachusetts Medical Society; Member of the 
Climatological Society; Member of the Socidte' de M/de- 
cine Pratique {Paris, France); one of the 
Physicians to the Anna faques Hos- 
pital, Newburyport, Mass. 










/ 



GEORGE S. DAVIS 

DETROIT, MICH. 



v 



Copyrighted by 
GEOKGE S. DAVIS. 



TABLE OF CONTENTS. 



CHAPTER I. 

THE PHYSIOLOGY OF SLEEP, 

Pag 
General Considerations on Sleep — The Necessity of 
Sleep; Proximate Cause or Causes — Functions of 
the Cerebrum — Registration of Impressions — 
Partial Memories; Sensory and Motor Localiza- 
tions — The Cerebrum as an Originator of Energy 
— Fatigue under Exertion — Waste and Repair — 
Antecedents of Sleep— State of the Circulation 
During Sleep — The Sense of Fatigue — Predis- 
posing Causes of Sleep — Amount of Sleep Nec- 
essary — Dreams — Dreaming an Indication of Im- 
perfect Sleep; often a Morbid Symptom i- 

CHAPTER II. 

INSOMNIA . 

General Divisions: i, Psychical; 2, Physical Causes 
— Pain as a Cause of Insomnia — Insomnia Due 
to Overwork of the Brain— Treatment — Insomnia 
Due to Morbid States of the Brain — Insomnia of 
Respiratory Origin — Insomnia of Heart Disease 
— Cardiac Dyspnoea — Insomnia of Gastrointesti- 
nal Origin — Insomnia of Cystitis — Insomnia 
from Genital Irritation — Insomnia of Toxic 
Origin — Insomnia of Continued Fevers and Its 
Treatment 29- 



CHAPTER III. 

HYPNOTICS. 



Opium and Narcotics — Alcohol and Other Stimulants 
— Bromide of Potassium and Bromides — Chloral 
— Sulphonal — Paraldehyd — Urethan — Somnal 
— Amylen hydrate — Chloralamid — Remedial 
Measures not Medicinal: (a) Baths, (b) The Wet 
Pack, (c) The Turkish Bath, (d) Shower and Jet- 
baths, (e) Electricity 89- 



Page. 



PREFACE. 



This little treatise, though long advertised to be a trans- 
lation of a recent monograph of Germain See in the MMecine 
Moderne, is in reality a product of my own pen, and whatever 
merit may belong to it, and all the faults and mistakes, must 
be credited to me. The monograph of Prof. See, with all its 
excellences, was found to be too brief and too incomplete for 
reproduction in the Leisure Library. A book on the subject 
had been promised, and the title announced, and I felt con- 
strained to make good the announcement by my own en- 
deavors; and all that I can say in palliation of my pre- 
sumption in attempting to write a treatise on a subject which 
has been recently handled so ably by Macfarlane, is that the 
topic is one that has intensely interested me, that I have 
bestowed on it considerable independent thought, and that I 
have endeavored concisely to state, in a common sense and 
practical way, the questions presented. It will be found, 
moreover, that as long as medical subjects continue to 
attract the attention of mankind, so long will there be trea- 
tises written on Sleep and its phenomena, and attempts, 
scientifically, to explain these phenomena and remedy those 
conditions which give rise to that distressing infirmity of our 
modern life — Insomnia. 

I desire in this place to state, once for all, that any 
coincidences between parts of this treatise and articles which 
have appeared during the past year in certain medical jour- 
nals (the Therapeutic Gazette, the Boston Medical and Sur- 
gical Journal, the Medical Age) are explained by the fact 
that, in the preparation of this book, I have used material 
which I had previously contributed to the columns of those 
journals. 

E. P. Hurd, M.D. 

Newburyport, Mass., Dec. ist, 1S91. 



CHAPTER I. 

THE PHYSIOLOGY OF SLEEP. 

It has been sufficiently demonstrated that during 
sleep the brain is relatively anaemic. The observa- 
tions of Durham, of Hammond, of Mosso, and others, 
have proved this. During sleep, all the encephalic 
blood-vessels are under a diminished pressure, as 
shown by the manometer. And this lessening of the 
active flow corresponds with a diminution of cerebral 
function. This is in accordance with the facts of 
physiology generally: the performance of function is 
characterized by vascular fulness and activity; the 
cessation of function is attended with decrease of the 
vascularity and volume of a part. 

The immediate cause of sleep, however, is not 
simply the shutting off of a portion of the blood-current 
from the brain. The lessening of the blood-supply is 
rather the accompaniment than the cause of sleep. 
The true cause is the torpor — engourdissement—oi the 
cerebral cells. This torpor may be the result of 
waste, unbalanced by repair, of the hemispherical 
ganglia, which become functionally inactive owing 
to diminution of oxidizing material, as well as to 
clogging of the venous and lymphatic channels by the 
accumulated debris of organic combustions. 

But this is not all. As the effete products of cell 
function have a paralyzing action on the cells them- 
selves — a truth exemplified even in the protoplasmic 



life of microbes, which are now known to generate by 
their activity ptomaines that are microbicide — so 
the toxic theory of sleep, first propounded by 
Preyer, has much probability in its favor. Preyer 
thinks that lactic acid is one of the principal waste 
products whose retention in the blood causes sleep, 
and refers to experiments of his own where lactic acid 
was injected in the veins of animals and produced a 
deep somnolent condition which was undistinguish- 
able from actual sleep. But lactic acid is only one of 
the toxic products of the living economy; the urinary 
salts are also destructive of cell life, and every cell 
is a laboratory of poisons, — leucomai'nes — which exer- 
cise their injurious effects on the organism as soon as 
the emunctories are incompetent thoroughly to per- 
form their task of elimination. Bouchard, who has 
performed many interesting experiments on animals 
by injecting the urine of various physiological and 
pathological states, finds that the urine of the day pos- 
sesses a toxicity twice as great as that of the night, 
and that the former produces narcosis, while the latter 
possesses convulsivant properties.* 

From these experiments the inference is drawn 
that during the period of waking activity the processes 
of disassimilation give rise to products which by their 
accumulation cause sleep. And this accumulation 
takes place because the elimination of these sub- 
stances by the urine goes on the more slowly the 



* La Mddecine Moderne, 1890, p. 183. 



nearer we approach the usual period of sleep. On 
the other hand, during sleep, the convulsivant sub- 
stances which result from denutrition cooperate in 
bringing about awakening. f 

In accordance with this theory, it might be expected 
that there would be a definite relationship between the labor 
done and the amount of sleep required — that hard brain 
work would necessitate more sleep than muscular work, and 
that those who toil little would sleep little. Unfortunately, 
theories, like parables, do not always "go on all fours." 
The relationship above spoken of is not mathematically 
established; the coal-heavers and diggers of the soil are the 
best, while the brain-workers are the poorest sleepers, and 
those that do little or no work of brain or muscle sometimes 
sleep with extraordinary soundness, and even have no diffi- 
culty in going to sleep in the daytime. 

There is reason to believe that sleep often ensues from 
simple torpor or lethargy of the cerebral cells, a state into 
which some persons are constitutionally prone to lapse. 
The state of the fcetus in utero may be regarded as one of 
continuous sleep, and it has been remarked that idiots and 
feeble-minded persons sleep much more than active-minded 
men. 

The Necessity of Sleep. — It is a law of 
nature that every kind of force or energy emanat- 
ing from the organic or inorganic world shall be 
the exact equivalent of some pre-existent kind of 
force. This is the doctrine of the correlation and 
equivalence and persistence of force now universally 
admitted. The power that drives the piston rod of 



fG. See, loc cit. 



— 4 — 
the steam engine existed latent in the coal as static 
force, originally coming in the form of dynamic force 
— light and heat — from the sun, that great primal 
source of power. 

In the galvanic battery we see chemical force 
converted into electricity, and in the conducting wire 
we have the transformation of electric force into heat. 
In the organic world we witness the metamorphosis 
of light, heat and chemism into those forces which are 
called vital* 



* "It is now an admitted doctrine that the nervous power 
is generated from the action of nutriment supplied to the 
body, and is therefore of the class of forces having a com- 
mon origin and capable of being mutually converted, in- 
cluding mechanical momentum, heat, electricity, magnetism, 
and chemical decomposition. * * * * What is called 
vitality is not a peculiar force, but a collection of the forces 
of inorganic matter in such a way as to keep up a living 
structure. * * * * The nerve force that is drawn from 
the waste of a given amount of food is capable of being 
transmitted into any other form of animal life. Poured into 
the muscles during violent conscious effort, it increases their 
activity; passing to the alimentary canal, it aids in the force 
of digestion; at other points, it is converted into sensible heat; 
while the same power is found capable of yielding true elec- 
trical currents. The evidence that establishes the common 
basis of mechanical and chemical force, heat and electricity, 
namely, their mutual convertibility and common origin, 
establishes, the nerve force as a member of the same group." 
— [Bain; Senses and Intellect, p. 65. 

The life of the highest as well as the lowest organisms 
is characterized by the manifestation of certain activities 



. — 5 — 
It is a truism to say that all organs that 
are exercised must have rest. After every con- 
siderable effort of the muscular system, a greater 
or less incapacity for further exertion results, and 
the subjective expression of this incapacity we 
call fatigue. The tired muscles obtain a meas- 
ure of repair during the intervals of work, and 
such intervals may be frequent during the working 
hours. We often rest one set of muscles when we are 
working another set. Even those actions which are 



derivable from the cosmic environment; the energy which 
we expend as nerve-force, muscular contraction, thought and 
will is but the expression of destructive changes taking place 
within our bodies. How much of nerve and muscular activity 
is the direct product of the breaking up of ternary compounds 
in the organism — fats, carbo-hydrates and glycogen, which are 
stored up as " reserves" in the tissues — how much is due to 
direct tissue metabolism, it is impossible to say; it is certain, 
however, that parts of the body that undergo exercise waste 
pari passu with that exercise, and that in undergoing disinte- 
gration, the static force that gave them structural form and 
function is set free as dynamical energy, and in accordance 
with the substratum throughout which it is liberated, mani- 
fests itself as some form of vital force. 

Plants expend little motion, and consequently their waste 
is inappreciable. Actiniae kept in an aquarium diminish 
little in bulk from prolonged abstinence. Even fish, which 
are much more active than other aquatic creatures, suffer 
little loss of substance when kept long unfed. The same 
remark applies with greater pertinency to cold-blooded animals 
and to hibernating animals. On the contrary, warm-blooded 
animals in a state of normal activity expend much energy and 



most continuous, as respiration and the pulsations of 
the heart, have distinct periods of suspension. It is a 
mistake to suppose that the heart and lungs never 
rest. After each contraction and dilatation of the 
heart, as Hammond reminds us, there is a pause of 
one-fourth the time of a beat in which the heart rests 
and is repaired. Hence the heart may be said to rest 
six hours out of the twenty-four. After each respira- 
tory act, there is a pause equal to one-third of the 
whole time; thus the lungs rest eight hours out of the 
twenty-four. But for the busy brain, there are no 
sufficient seasons for rest during the working hours. 
The latest, most elaborate, most noble product of 
evolution, superadded to the spinal and sensory 
ganglia of the animal economy ages after the auto- 
matic action of these centres had been established by 



waste much substance. f This waste must be made good by 
repair,and the conditions of repair are a normal supply of food, 
a normal circulation, and opportunity for appropriation of 
pabulum. If this opportunity be not afforded from moment to 
moment; if synchronous with waste, repair cannot go on, 
suitable seasons must ensue when the equilibrium may be re- 
stored. If the system cannot in its entirety be refected while 
work is going on, work must stop while the system is being 
refected. The machine is out of repair, and business must 
be suspended while it is having an overhauling. These 
considerations give hints as to the true meaning of sleep. 



t Vide Herbert Spencer's Principles of Biology, Vol. i, p. 170, from 
which I have borrowed several illustrations of the law stated. The only 
satisfactory explanation of the phenomenon of sleep is furnished by such 
biological inductions. 



organization, and superadded for the greater elabora- 
tion of faculty and for the more complete co-ordina- 
tion of faculty with the conditions of existence, the 
cerebrum is still the latest development in the evolu- 
tion of the individual, and perhaps the most hetero- 
geneous and unstable in its molecular constitution. 

I do not propose to go into any lengthy con- 
sideration of the functions of the brain. I 
assume the cerebrum to be the seat of sensa- 
tion, thought, volition. The psycho-motor centres 
are located in the post-frontal and parietal regions. 
No such precise localization for the purely psychical 
centres is yet possible. " The endless variety 
in the character and complexity of our cerebral 
activities," says Macfarlane, " implies the exist- 
ence of a like multiplicity of centres." Localization 
we do indeed know in part. Ferrier's teachings with 
regard to the motor centres for the muscular group- 
ings of the face, upper and lower extremities, etc. 
(which are mostly located along the fissure of 
Rolando), are generally accepted. The visual centre 
is in the occipito-angular region; the auditory is in the 
temporo-sphenoidal convolutions. The seat of smell 
is probably in the tip of the temporo-sphenoidal lobe, 
that of taste is in the region of the subiculum cornu 
ammonis. 

The seat of cutaneous sensation — tactile, thermic, 
pathic — located by Ferrier in the gyrus hippocampi 
and gyrus fornicatus, seems the rather, in accordance 



with a multitude of facts collected by Dana,* to be in 
the motor areas of the cortex. A study of cases 
shows that the the sensory centres for special parts of 
the body, i. e., face, arm, or leg, are in general iden- 
tical with the motor centres for those parts, but are 
larger and more diffuse. The tactile sensation seems 
to be more strictly confined to the motor areas, f 

The centres of the psychical operations are 
known to be somewhere in the cortex, but apart from 
the general vague division of mind into feeling, intel- 
lect, and volition, and the recognition of the fact that 
these three aspects of mind are so dependent among 
themselves, although characteristic in their manifesta- 
tions that no one could exist alone, no further division 
of mind is possible in the present state of science. 

There is, however, a sort of psychical differentia- 
tion with definite localization of- which we are war- 
ranted in speaking, and as the subject is of import- 
ance in connection with the physiology of sleep, I 
may be pardoned such digression as may be neces- 
sary to set forth views which may now be considered 
as data of science. 

Ribot, in his "Diseases of Memory," remarks 
that in physiology the distinction of partial memories 
is now currently received. " Memory resolves" itself 
into memories, just as the life of an organism resolves 



*" The Cortical Localization of the Cutaneous Sensa- 
tions," Journal of Mental Diseases, Oct., 1888. 
•f Dana, loc cit. 



itself into the life of the organs, tissues, and anatom- 
ical elements that compose it." 

As memory is only the sum of partial mem- 
ories, and all our knowledge (based on memory) is 
primarily derived through the senses, and as all the 
sense-organs have their centres in the cerebrum where 
the residua of sensations (to use Maudsley's expres- 
sion) constitute the memories of each special sense, 
:S0 certain diseased conditions may obliterate one set 
of sense-memories by destroying their anatomical 
substrata, leaving, it may be, intact the memories of 
other senses. 

Charcot, in a recent lecture, has given us a good 
instance of this suppression of certain groups of 
memories. It was a case of loss of the mental vision 
of objects — forms and colors — coming on suddenly in 
a subject noted for great intellectual activity, but 
especially for the strength of his visual memory. 
This- individual would recall the principal features of 
a landscape, a painting, a play, with extraordinary ex- 
actness and vividness; his imagination was keen, and 
he excelled in perspective. He could readily recall 
what he had read by the mental images of words, 
lines, sentences, etc., presenting themselves. His 
memory of persons and places was wonderful. After 
the accident to which allusion has been made, and 
which seems to have been of the nature of a limited 
embolism, he lost his visual memory of forms and 
colors, and was obliged in the management of his 
commercial affairs to have recourse to other forms of 
-memory (the auditive, tactual, etc.), which were un- 
impaired. The city where he lived, his very home, 
and the faces and forms of the members of his family 
were at first strange to him; he recognized nobody 
•except by the voice; he could only find his place of 



business by inquiry. Little by little his visual mem- 
ories returned, but never completely. He had lost 
the faculty of drawing; could no longer sketch the 
form of any object which he had once seen. His 
memory of colors was gone; he could not form the 
mental image of black, white, red, etc., and when any- 
thing of a bright hue was presented to him, he could 
not recognize the color. The larger part of what he 
had learned by reading was forgotten, while the 
memory of what had been acquired by the auditory 
sense was as vivid as ever. 

This gentleman wrote to Charcot that his "in- 
terior vision," once so active and perfect, "had com- 
pletely disappeared." He could no longer represent 
to himself the forms and features of his wife and 
children, or any other person or object with which 
he had been familiar. His dreams were completely 
changed; he now no longer dreamed of persons and 
places, but of voices and words. A remarkable con- 
sequence of the loss of this mental faculty was the 
change of character which he had experienced. He 
found himself much less prone to sorrow, sympathy 
and moral emotion than formerly. Having recently 
lost a valued relative, he felt much less poignant grief 
than we would have felt could he have represented to 
himself by the interior vision the physiognomy of this 
relative, the phases of the disease through which he 
had passed, and especially, if he could have pictured 
to himself the external effect produced by this death 
on the members of his family. He concludes his let- 
ter by the remark that he is now obliged to say tO' 
himself the things which he wishes to retain in his 
memory, whereas, before the occurrence of his cere- 
bral lesion, he had only to photograph them by sight in 
order to remember them. 



Charcot concludes some very judicious and in- 
structive comments on this interesting case, of whose 
details we have given but an imperfect idea, by the 
following observations: " It cannot now be denied 
that the possible and actual suppression, in numerous 
instances, of an entire group of memories, of a whole 
category of commemorative images, without the par- 
ticipation of other groups, of other categories, is a 
capital fact in pathology as well as in cerebral physi- 
ology; it leads necessarily to the admission that these 
divers groups of memories have their seat in certain 
determined regions of the encephalon, and adds an- 
other proof to those already existing that the hemi- 
spheres of the cerebrum consist of a certain number of 
differentiated organs, of which each possesses its proper 
function, while remaining in the most intimate con- 
nection with the others. This last proposition is, 
moreover, to-day generally admitted by those who 
study the functions of the brain, not only in animals, 
in the laboratory, but also, and especially, in man, by 
the procedures of the anatomo-clinical method." 

To sum up, then, the cerebrum is the great 
centre of sensation, perception, and ideation, of con- 
scious, emotional, voluntary activity. Pulses of mole- 
cular motion from the brain are being continually 
diffused throughout the body, and the healthy per- 
formance of its office by every part of the body de- 
pends largely on these gushes of nervous energy. 
There are differences in molecular activity between 
nerve fibres and nerve cells. "While the matter com- 
posing a cell is built up of enormously complex ag- 
gregates of molecules, wholly unshielded from ex- 



ternal disturbance, the nerve matter of a fibre is pro- 
tected throughout its entire length by a membranous 
sheath. And while it is probable that the action go- 
ing on in a cell consists in the continual fall of un- 
stably arranged molecules into a state of more stable 
equilibrium, from which a fresh rush of blood is con- 
tinually raising them to their unstable state, it is 
probable that the action going on in a fibre consists in 
the successive isomeric transformation and retrans- 
formation of the system of molecules which make up 
the fibre." " The cell is the place where nervous 
energy is liberated, while the fibre is a path along 
which nervous energy is transmitted."* 

The amount of molecular energy locked up in a 
nerve centre is proportionate to the amount of unsta- 
ble nerve matter awaiting decomposition; and the 



*This view is well brought out by Virchow. He be- 
lieves that all function (or activity of all kinds in tissues) is 
due to changes of place in the minute particles of the cell 
contents. This change of place is almost instantaneously 
transmitted through all the cells in proximity. A change in 
the electrical state of the part is connected with it. Vir- 
chow's view that restitution of function does not always de- 
pend on a fresh absorption of nutritive material may per- 
haps seem novel. Rest alone, he says, is often sufficient to 
enable the cells in a very short space of time to renew their 
activity. The molecules which had quitted their usual posi- 
tion gradually revert to it, and hence are ready for function 
again. Virchow seems to have proved this by experiments 
on nerves which have been cut out of the body. — [Cellular 
Pathology, p. 327. 



— 13 — 

greater the quantity of motion liberated, the less of 
material remains for the liberation of motion.* Hence 
the diminished readiness with which the nervous cen- 
tres respond to stimuli after a few repetitions of the 
disturbance. The amount of explosive material is 
lessened with each explosion. The enfeeblement of 
nerve-centres when caused by moderate action is in- 
conspicuous, for the disintegrated mass speedily re- 
integrates itself from the materials brought in the 
blood.f But if the stimulation and consequent dis- 
charge are violent, or very often repeated, then repair 
falls so far in arrear of waste that the nerve centres 
become partially or completely incapacitated. "All the 
unstable substance within easy reach of the incoming 
disturbance has been decomposed, leaving only such 
part as is most removed from ordinary disturbances 
and can be affected only by excessive ones." As ex- 
amples we need only to be reminded of the tired 
horse that needs persistent urging and the continued 
and often excessive use of the lash to make him con- 
tinue his pace. Also of the effect of friction of the 
skin in causing paralysis of the vaso-motor nerves and 
cutaneous congestion. The familiar experiment of 
the effect of irritating the web of the frog's foot is to 
the point. The arteries are at first contracted under 
the stimulus; "the strong impression conveyed to the 
vaso-motor centres there liberates an excessive dis- 



* Spencer's Psychology, vol. i, p. 
f Herbert Spencer, he. cit., p. 89. 



— 14 — 
•charge along the fibres supplying those arteries, caus- 
ing spasmodic contraction of their muscular coats. 
The second result is that these arteries dilate, losing 
their normal contractility; they become distended 
with blood, and the part is congested. That this is 
due to extreme prostration or temporary paralysis of 
the vaso-motor centre has been clearly proved, for if 
the nerve-trunk containing the vaso-motor fibres be 
dissected out and artificially irritated, the dilated ar- 
teries instantly contract."* 

Mr. Herbert Spencer, from whom I have bor- 
rowed these illustrations respecting the vaso-motor 
nerves, has hardly done more than gather up into a 
complete whole the generalizations of his leading sci- 
entific contemporaries. Virchow, for example, in his 
Cellular Pathology, p. 149, has said substantially the 
same respecting the action of vaso-motor nerves 
under stimulation, and the readiness with which they 
.are exhausted. In the smaller vessels, with few mus- 
cular fibres, the exhaustion follows so speedily the 
stimulation that it seems as if the irritant had pro- 
duced no contraction, so soon does relaxation follow. 

These familiar truths explain why the brain 
needs the rest of the night. Repair and waste are 
not evenly balanced during the waking hours. Waste 
has got in excess of repair. Not that no repair has 
been going on during the working hours — nutrition is 
actively going on at all times, and in the spinal cord 



Loc. cit., p. 87. 



— i5 — 
and medulla oblongata it is probable that repair ever 
keeps pace with waste, or falls but little in arrear, 
equilibrium being quickly restored. The peculiar 
functions of these lower centres are of an automatic 
kind, stimuli always producing responsive discharges 
along established lines. It would certainly be for the 
advantage of every species in the struggle for exist- 
tence that those automatic functions should be per- 
formed at such an even, uniform rate that repair and 
waste should be in equilibrium. Such is the condi- 
tion of these nerve centres. From minute to minute 
brief pauses occur, when waste is made good by re- 
pair. This was shown to be true in respect to respira- 
tion, the pause after each respiratory act giving the 
bulb sufficient time for repose and repair. 

With the cerebrum the case is somewhat different. 
" Its substance is consumed by every thought, by 
every action of the will, by every sound that is heard, 
by every object that is seen, by every substance that 
is touched, by every odor that is smelled, by every 
painful or pleasurable sensation, and so on. Each 
instant of our lives witnesses the decay of some por- 
tion of its mass, and the formation of new material 
to take its place."* 

Hence the need of that periodical repose we call 
sleep. Sleep becomes emphatically "tired Nature's 
sweet restorer," "balm of hurt minds," "chief nour- 



* Hammond, "Sleep and its Derangements," p. 12. 



isher in life's feast." In this adaptation of organisms 
to the waste of the day and the repair of the night, 
Herbert Spencer sees an example of the principle of 
survival of the fittest. "An animal so constituted 
that waste and repair were balanced from moment to' 
moment throughout the twenty-four hours, would, 
other things being equal, be overcome by an enemy 
or competitor that would evolve greater energy dur- 
ing the hours when light facilitates action, at the ex- 
pense of being less energetic during the hours of 
darkness and concealment. Hence there has neces- 
sarily established itself that rhythmical variation in 
nervous activity which we see in sleep and waking." 
(Principles of Psychology, vol. i, p. 88). 

Antecedents of Sleep. — There is every reason to 
believe that one of the antecedents of sleep is a cer- 
tain change in the composition of the blood circulat- 
ing in the capillaries of the pia mater, where by the nutri- 
tion of the cortical cells is diminished. This change 
may be regarded as an accumulation of waste extrac- 
tives. There is also doubtless another factor, as 
stated by Pfiugger; the brain is extremely sensitive 
to the want of oxygen, e.g., when frogs are deprived 
of this element for any length of time, they fall into 
a condition resembling sleep. Some experiments of 
Pettenkofer and Voit make it apparent that oxygen 
accumulates in the blood during sleep to be utilized 
during the waking hours; deficiency or absence of 
this "change-compelling" element may well cause 



— i7 — 
that lethargy of function whose full expression is 
sleep.* 

Another antecedent of sleep is lethargy of the 
circulation. There are probably several factors in 
this change. Less blood is attracted to the cortex 
by the cells becoming functionally inactive, and the 
tired brain sends diminished energy to the heart, and 
there is a slowing of the circulation. With a diminu- 
tion of vaso-dilator influence in the higher ganglia 
there may be an augmentation of vaso-dilator in- 
fluence in automatic ganglia lower down (the inhib i- 
tory agency of the hemispheres being withdrawn), 
hence a narrowing of the calibre of the cerebral 
arterioles and a lessened blood supply. During 
sleep, then, it is believed that the proper functions 
of the cerebrum are mostly suspended, nutrition 
only being active; the constricted arterioles supply- 
ing just enough blood to the nerve cells that the 
requisite reparative processes may be performed. 



* These experimenters, by an ingenious laboratory con- 
trivance, were enabled to measure the amount of oxygen 
inhaled and of carbonic acid exhaled during the 24 hours. 
A healthy man was put into the test chambers with the light 
occupation of taking to pieces the works of a watch. Of the 
total quantity of oxygen inhaled by him, 33 per cent, was 
absorbed during the day, and about double, 67 per cent., 
during the night. This goes far to prove that night is the 
time for storing up oxygen to be used during the day in the 
production of work. — [North British Review, June, 1868, p. 
269^ 



This relatively anaemic condition of the cerebrum 
during sleep has been proved by numerous well at- 
tested observations, as those of Sir Astley Cooper, 
Pierquin, Donders, Durham, Hammond, Mosso, and 
others. The experiments of Hammond were made 
on dogs from whose crania portions of bone were 
trephined, exposing the brain and its membranes. 
The details of these experiments are now sufficiently 
known since their publication in his book on "Sleep 
and its Derangements." Durham's observations, 
which were several years prior to Hammond's, also 
pertained to dogs. 

Pierquin's case is recorded by Dendy in his "Philo- 
sophy of Mystery," and elsewhere.* A girl in Montpellier 
had lost a large portion of her scalp and skull. The brain 
could be seen for a considerable extent of surface. When 
she was in dreamless sleep, her brain was motionless and 
low within the cranium; but when her sleep was imperfect 
and she was agitated with dreams the cerebrum moved and 
beat; more blood coursed through the vessels of the pia 
mater, and the brain protruded through the holes in the 
skull. * * * When she was awake and in vigorous 
thought, the brain swelled, and protrusion was very observ- 
able. 

Professor Mosso, of Turin, had the rare oppor- 
tunity of making similar observations on three per- 
sons, each of whom had lost a portion of the skull. 
His studies of the cerebral circulation during sleep 



* Combe's Physiology, p. 143. Jarvis' Physiology, p. 
432. American Annals of Phrenology, No. 1, p. 37. 



and during the waking moments have been the most 
thorough, and go to show: " i. That in the act of 
going to sleep a dilatation and relaxation of the ves- 
sels of the forearm occur, with a corresponding con- 
traction in the vessels of the brain, this change be- 
coming most pronounced during deep sleep. 2. That 
all external stimulation, however slight, such as a ray 
of light falling upon the eye, a noise, etc., is attended 
by contraction of the vessels of the forearm, greater 
blood pressure, and an .increased flow of blood to the 
brain. 3. That these changes are accompanied by a 
modification of the respiratory rhythm, and an ac- 
celeration of the pulsations of the heart. 4. That 
during sleep, the quantity of blood in the brain is sub- 
ject to fluctuation without any apparent cause. 5. 
That all mental activity is attended by an increased 
quantity of blood in the brain." * 

These facts seem to teach that the sleep state is 
attended with relative ansemia of the brain, and that 
the amount of blood supply to that organ is in ratio 
with the mental activity. 

Hammond regards this diminution of the quantity 
of blood circulating in the brain as the immediate 
cause of sleep, and affirms that whatever cause is 



*" Insomnia and its Therapeutics," Macfarlane, p. 16. 
Mosso devised special instruments by which he took tracings 
of the movements of the brain, the pulsations of the heart, 
etc.; he also invented the Plethysmograph, for estimating 
the quantity of blood in the forearm and hand. 



capable of lessening the quantity of blood in the 
brain is also capable of inducing sleep. 

To this view has been opposed the fact that pa- 
tients suffering from general anaemia (from haemor- 
rhage, chlorosis, cachexia, etc.), are often the victims 
of insomnia, and that conditions of plethora are often 
attended with troublesome somnolence. Ligature of 
the carotids in animals does not produce a state re- 
sembling true sleep, and faradization of the cephalic 
ends of the two divided cervical sympathetic cords in 
animals, while it produces considerable cerebral an- 
aemia, does not bring about the least tendency to 
somnolence.* 

These objections appear to me to be well taken, 
and it seems probable that the vascular and cardiac 
modifications are, as Vulpian says, "only accessory 
and adjuvant," " concomitant or consecutive, play- 
ing no essential role in the physiology of sleep." 

At the same time, there is no doubt that " slight 
and gradual anaemia of the brain is conducive to 
sleep," and therefore we see the utility, in some cases 
of insomnia, of hot pediluvia, cold, wet cloths to the 
head, etc. 

The Sense of Fatigue. — Subjectively, sleep is pre- 
ceded by a sense of fatigue, which is the more pro- 
nounced the greater the labor which has produced it. 
Fatigue may be regarded as an expression of waste 



*See these objections forcibly stated by Vulpian in his 
Zefons sur VAppareil Vaso-Moteur , t. i, p. 150. 



unbalanced by repair; according to Preyer, lactic acid 
and creatine accumulating in the blood cause this 
sensation by their paralyzing action on the cells of 
the cortex. 

"Fatigue," says Benedikt,* "is a property inher- 
ent in all the nervous and muscular tissues; but the 
almost unlimited duration of certain automatic move- 
ments of pathological nature proves that the fatigue 
which supervenes after voluntary movements has its 
origin in the motor centers of the cortex. * * * * 
The sensation of fatigue is in a certain sense a guar- 
anty of safety for the muscular apparatus. In certain 
pathological states, often even by the energy of the 
will alone it may be overcome. But there then fol- 
lows a still greater realization of fatigue, which may 
be the result of complete exhaustion." 

Normal fatigue easily leads on to a condition of 
sluggishness and languor known as sleepiness. The 
eyelids feel heavy, the muscles relax, there is an in- 
stinctive disposition to shirk work, an inability to fix 
the attention on anything which requires thought, a 
sensation of supineness and enervation, a considerable 
obtuseness of the senses. Yawning is a phenomenon 
"indicative of a wearied attention." "The head nods 
and droops upon the breast, and the body assumes 
that position which is most conducive to ease, com- 
fort, and entire muscular inactivity." 

Another subjective antecedent of sleep is failure 



*La MMecine Modeme, 1891, p. 67. 



of the attention. To this end, absence of sensorial 
impressions is an important condition of sleep. There 
are certain influences which are predisposing causes, 
such as darkness and silence and muscular rest. 
Habitual sensations, as the continuance of an accus- 
tomed sound, are of the same class. It is owing to 
the power of habit that some persons can sleep more 
soandly in the neighborhood of noisy mills and cata- 
racts, than elsewhere, the attention of the individual 
being more attracted by the suspension of the sound 
than by its continuance; for as the exercise of the 
attention implies an awakened and concentrated con- 
sciousness, during such exercise sleep is, in the nature 
of the case, impossible. Other predisposing causes 
are gentle tranquilizing sounds, such as the piping of 
crickets, the rustling of foliage, the hum of bees, 
hearing a dull book read, etc., which conduce to sleep 
by making on the sensorium a series of monotonous 
impressions which are neither interesting enough, nor 
powerful enough to keep the attention aroused (Car- 
penter). 

Ovid places the cave of Somnus in the country 
of the Cimmerians, the fabled land of shadows, of 
silence, and of gloom. The river of Lethe flows there, 
and invites to sleep by its murmur, and poppies luxu- 
riate before the cave of the drowsy god. Spencer 
locates the palace of Somnus in a dull and darkling 
part of the earth. Archimago sends a little spirit 
„down to Morpheus to fetch him a dream: 



— 23 — 

" He making speedy way through spersed ayre, 

And through the world of waters wide and deep, 

To Morpheus' house doth hastily repaire 

Amid the bowels of the earth full steepe, 

And low, where dawning day doth never peepe, 

His dwelling is. There Tethys his wet bed 

Doth ever lave, and Cynthia still doth steepe 

In silver dew his ever drooping head, 

While sad night over him her mantle still doth spreade. 

And more, to lull him in his slumber soft, 

A trickling stream from high rock tumbling down, 

And ever drizzling rain upon the loft, 

Mixed with the murmuring wind, much like the soune 

Of swarming bees did cast him in a swoone, 

No other noise, nor people's troublous cries, 

As still are wont to alarm the walled towne, 

Might then be heard, but Careless Quiet lies 

Wrapped in eternal silence far from enemies." 

Amount of Sleep Necessary. — As sleep is a con- 
structive process, it would seem that the amount of 
sleep taken should be proportionate to the mental 
and physical exercise of the waking hours. The 
reparative value of sleep, however, is more depend- 
ent on the depth and intensity of the sleep than on 
its duration. The invigoration which follows sound, 
dreamless sleep is remarked by every one; a little 
sleep of this kind is worth many hours of disturbed, 
dreamy sleep. It would seem that absolute quies- 
cence and suspension of function is that condition of 
the cortical cells most favorable for nutrition and 
repair. The principle of making up for lost sleep is 
a correct one; persons habituated to six or seven 



— 24 — 

hours' sleep a day may pass without inconvenience a 
night or two without sleep, provided they can make 
up for this loss by a more prolonged sleep afterwards. 
It is by dint of the habit of sleeping profoundly 
when they do sleep, that some persons sleep but few 
hours out of the twenty-four, and yet continue in 
health. Frederick the Great and John Hunter are 
said to have required only five hours' sleep a day; 
Pitt used to restrict himself to three hours. The 
briefest sleepers are generally men of the greatest 
mental activity. The best scholars, thinkers and lite- 
rary men, according to Carpenter, do not spend more 
than one-fourth of the diurnal cycle in sleep. 

Persons of lymphatic temperament are said to be 
the greatest sleepers, from natural lethargy of the 
nervous centers. 

Hard, muscular toil promotes somnolence more 
than hard brain- work; the husbandman and day 
laborer sleep longer and more profoundly than the 
student or professional man. The waking state of 
such persons is characterized by great activity; the 
wear and tear of the muscular system is immense, 
and long seasons of rest are needed, during which 
the physical and vital energies shall be largely occu- 
pied with the work of muscular reparation. Blood 
goes from the brain to the muscle, and there is rela- 
tive anaemia of the cortex, a condition favorable to 
the inertia of sleep. Moreover, the cerebral activity 
of even the humblest day laborer is not inconsider- 



— 25 — 
able — the sensory, perceptive, and voluntary faculties 
are kept constantly employed during their daily occu- 
pations. They often toil for hours in obedience to a 
painful exercise of the will, amid an almost overpow- 
ering sense of muscular weariness. Now, a purely 
voluntary act fatigues the brain more than an involun- 
tary or automatic one. Hence, the protracted sleep 
of the day laborer must be due in a considerable 
degree to cerebral waste. 

The relationship of muscular exercise and muscu- 
lar fatigue to the intra-cranial energies and circula- 
tion may not be demonstrably clear, but the fact is 
none the less certain that muscular exertion is one of 
the most powerful promoters of sound sleep. 

Dreams. — Dreams, from a psychological point of 
view, constitute the most interesting phenomena con- 
nected with sleep; from a medico-physiological point 
of view, they are chiefly of interest as indicating that 
the sleep is not sound, i. e„ only partial. In dreams, 
the cerebrum is in part awake; the automatic (earliest 
•evolved, most organized) centres of mind resume a 
measure of their activity, while the will* is still dor- 



* I use the term as expressive of the sum of the higher 
mental activities. These may be regarded as the latest 
evolved, most consummate results of evolution — the last 
developed in individual biological history and the soonest 
lost. The effects of physical tire earliest manifest themselves 
in modifications of the functional efficiency of the organic 
substrata of these faculties; the truly automatic substrata 
are more stable and capable of more prolonged, unresting 



— 26 — 

mant. A limited area of brain is brought into a con- 
dition of waking excitement; certain ideas and emo- 
tions result, which, not being modified by comparison, 
and reflection by other ideas and feelings which are 
asleep, present a phantasmagorical succession of 
images to the consciousness. 

Hammond suggests that the cause of that sus- 
pension of the judgment which characterizes sleep 
resides in some alteration in the circulation of the 
blood in that part of the brain which presides over 
the judgment, whereby its power is suspended and the 
imagination left free to fill the mind with its incon- 
gruous and fantastic images. 

And yet, judgment, like volition, is a very com- 
plex phenomenon. It implies the possession of one's- 
principal mental acquisitions, one's stores of experi- 
ences; it implies comparison, choice. The experi- 
ences themselves may not be actually present to the 
consciousness, but certain residua — unconscious gen- 
eralizations — from these experiences, must be there 
that judgment may be exercised on the case at issue. 
It is plain that the imperfect sleep consciousness is 
inadequate to such exercise of comparison. 

We have not time to linger on this interesting 
topic covering which volumes have been written. It 
is perhaps better to leave this domain to the poet and 



activity, as is shown by abundance of pathological facts. 
(See Hughlings Jackson's Lectures on Evolution and Dissolu- 
tion in the Nervous Centres.) 



— 2 7 - 

the metaphysician, to whom, as rightful property, 
dreams belong. We may remark, in passing, that 
the loss of association of ideas prevails as much in 
dreams as in the waking state. 

" Lulled in the countless chambers of the brain 
Our thoughts are linked by many a hidden chain. 
Awake but one, and lo! what myriads rise. 
Each stamps its image as the other flies. 
Each thrills the seat of sense, that sacred source 
Whence the firm nerves direct their mazy course, 
And through the frame invisibly convey 
Their subtle, quick vibrations as they play." 

The dream images that "thrill the seat of sense" 
are a revival of registered sense impressions rendered 
peculiarly vivid because the natural channels between 
the outward world and the sensorium are closed. 
Hence, not being corrected by an incoming torrent of 
objective impressions, they engross the relatively 
meagre and imperfect sleep-consciousness, and seem 
realities. The same brain tract which is excited by 
the objective sense impression is occupied by the 
revived subjective image (Carpenter, Bain, Spencer). 
If we dream of things seen or felt or heard, it is the 
centres of those respective senses that are called into 
action, with such portions of the hemispherical (cor- 
tical) ganglia as have organic connections with them. 
It is remarked by' Macfarlane that when many cen- 
tres are active, dreams are consistent and coherent, 
while when few centres are working, they are unreal 



— 28 — 

and extravagant, t. e., the difference in the quality of 
the dreams depends on the depth of the sleep.* 

Dreams are principally of interest to the phy- 
sician as being an indication of unsound sleep. The 
dreaming period seldom comes on in health till the 
time for waking approaches. Then the centres that 
are most automatic one by one recover their functional 
activity, those which represent the higher mental 
powers still remaining dormant. It is doubtless true 
that in sound sleep we never dream. If anything has 
been settled by the labors of physiologists during the 
past forty years, it is I think this, that the vascular 
and other conditions of perfect sleep forbid any men- 
tal manifestations. The condition of sound sleep is 
one of complete psychical inertia. A transcendental 
philosophy which teaches that the mind is always 
conscious and always active must have some higher 
foundation on which to rest than common sense and 
experience. 

If the dreaming period comes on early, it is evi- 
dence of some irritation in some part of the body 
which is disturbing the rest of the brain. Thus, un- 
seasonable dreaming is often symptomatic of indiges- 
tion, teething, a febrile condition, the influence of 
some toxic agent (tea, coffee, alcohol, etc.), and when 
dreams become pathological, it is a part of the phy- 
sician's duty to discover the cause and remedy it. 



' Loc. cit., p. 3r. 



. CHAPTER II. 

INSOMNIA. 

If the essential condition of sleep be torpor of 
the centres of conscious mentality, everything which 
excites these centres and keeps them functionally 
active will promote insomnia. 

In discussing the causes of insomnia I shall adopt 
in part Professor See's classification, and shall con- 
sider these cases as: I. Psychical; and, II. Physical. 

I. Under the head of Psychical Insomnia are 
included cases of sleeplessness due to to mental emo- 
tion, to thought, worry — i. <?., internal causes not di- 
rectly dependent on organic states or outward excita- 
tions. This kind of insomnia is that with which the 
author of " Night Thoughts " was (presumably) 
affected: 

" From short, as usual, and disturbed repose, 
I wake. How happy those that wake no more! 
I wake emerging from a sea of dreams 
Tumultuous, where my wrecked despondent thought 
From wave to wave of fancied misery 
At random drove, her helm of reason lost! " 

Insomnia of the psychical order is illustrated in 
the student who is anxious about his examinations 
and cannot obtain rest till the result is known; in the 
candidate for political honors who cannot sleep till 
the election is over and his fate is decided; in the 
mother who will watch over her sick child night after 



— 3° — 
night, not closing her eyes till the crisis of the sick- 
ness is passed. Multitudes of such instances happen 
in daily experience. In order that natural sleep may 
occur, the mind must be tranquil; on this point it is 
useless to enlarge. 

The pure hypnotics — chloral, paraldehyd, ure- 
than, sulphonal — are generally quite efficacious in the 
insomnia due to emotional causes, the intensity of the 
insomnia being of course proportional to the intensity 
of the disturbing cause. Business cares and anxieties 
of all kinds, and, I may add, homesickness and 
disappointments, often produce a most obstinate 
wakefulness, which hardly yields to even large doses 
of chloral; sulphonal is almost without effect. In 
•such cases the therapeutist is almost without re- 
sources. 

" Who shall minister to a mind diseased, 
Pluck from the memory a rooted sorrow, 
Rase out the written troubles of the brain, 
And with some sweet oblivious antidote 
Cleanse the stuffed bosom of that perilous stuff 
Which weighs upon the heart?" 

Under the head of psychical insomnia may also 
be classed sensorial disturbances of an unusual, in- 
tense, or persistent nature, whether of sight or of hear- 
ing, which prevent sleep. But these causes are so 
familiar to everybody that it suffices simply to men- 
tion them — illustrations are innumerable. Prof. See 
alludes to the effect often produced by prolonged 



— 3i — 
application of the eyes to reading and to the micro- 
scope, especially in the evening; this frequently pro- 
vokes subjective excitations— " phosphenes " — whose 
constant reappearance prevents repose. It is useless 
to say that this kind of insomnia, being caused by 
physical agents, might properly come under the next 
division. 

II. Under the head of Physical Insomnia, I 
shall, i, take up the group of physical causes, fore- 
most among which are organic conditions productive 
of PAIN. If an irritation emanating from any organ 
or tissue may keep consciousness aroused and the 
cortex active when not painful, how much the more 
will it be likely to produce insomnia when raised to 
that degree of intensity known as pain ? Pain implies 
a peculiar excitation of the sensory cortical centres 
and an awakened consciousness, and its very exist- 
ence is inimical to sleep. 

It is not necessary to dwell long on the causes of 
pain. It may be peripheral or visceral; may be due 
to inflammatory states of the nerve centres or their 
membranes, or to functional disturbances of nerves, 
■contituting neuralgia; to conditions of anaemia or 
hyperaemia; to inflammation and suppuration; to ul- 
cerative processes; to the pressure of tumors, exuda- 
tions, etc. 

The leading therapeutical indication is to remove 
the cause. This may be easy of accomplishment, as 
when the pain is from a carious tooth, or an abscess, 



or it may be impossible to meet, as in many cases of 
locomotor ataxia with douleurs fulgurantes, in the pain 
of internal, cancer, etc. The pain of migraine offers 
this peculiarity that it generally yields to the desire 
for sleep; other forms of neuralgia are apt to be 
worse at night. Often the causal indication must be 
kept in abeyance; the first thing to attend to is the 
indicatio morbi. A hypodermatic injection of morphine 
may be imperatively required, and it may be waste of 
time to attempt to relieve the pain by other remedies. 
In the insomnia due to cancer, to acute inflammation 
(pleurisy, pneumonia, peritonitis, pericarditis), abscess, 
the lightning pains of ataxia, to severe neuralgic at- 
tacks, it will not always be possible to obtain the 
relief requisite for sleep without recourse to opium or 
morphine. It is undeniable, however, that in anti- 
pyrin, phenacetin, acetanilid, and other of the new 
analgesics, we may often find good and comparatively 
harmless substitutes for opium or morphine. Thus 
there is a large amount of testimony to the benefits 
obtained from phenacetin, antipyrin, etc., in the pains 
of acute rheumatism, facial neuralgia, hemicrania, 
lumbago and pleurordynia, neuritis, zona, sciatica, 
and even in the douleurs fulgitr antes of tabes. 

The analgesic action of belladonna, cannabis 
Indica, hyoscyamus, is sometimes sought in insomnia 
due to pain; not much reliance, however, can be 
placed on any narcotic but opium. 

There will always be one objection against opium 



— 33 — 
when used for hypnotic intent; it is not a good hyp- 
notic, as it produces and long keeps up, in many per- 
sons, a cerebral excitation incompatible with sleep; 
hence where other analgesics, as antipyrin, acetanilid, 
prove to be sufficient to quell the pain, they should 
always have the preference. 

2. Insomnia due to overwork of the brain is the 
insomnia of cerebral hypersemia. Prolonged study, 
constant application to business, literary undertak- 
ings, speculative enterprises, etc., demanding vigilant 
thought and entailing much worry and anxiety are 
fruitful sources of insomnia. At the same time, ex- 
haustive mental toil may be carried on with impunity 
provided the hours of sleep be not interfered with; 
provided also that suitable seasons of relaxation and 
diversion be snatched during the working hours. It 
is unremitting mental toil and worry that kills. 

The theory that during mental work certain dis- 
tricts of the brain are flushed with blood is consonant 
with all the experiments and observations whereby 
we have acquired a knowledge of the physiology of 
the brain. It is also known that the blood supply to 
the brain is controlled by the vaso-motors, and it is a 
legitimate inference that in the insomnia from mental 
overwork the blood vessels of the cerebral cortex are 
overfilled from exhaustion of these nerves, or, what 
means the same thing, from exhaustion of the tonicity 
of the blood vessels. 

Doubtless the age in which we live is peculiar in 



— 34 — 
the sense that multitudes are obliged to toil harder 
with their brains than any previous race. Never be- 
fore, perhaps, in the history of mankind, did arduous 
strife and competition involving the higher nervous 
centres become so necessary. The present genera- 
tion is the heir to all the acquisitions of the past, but 
these have been an ever accumulating burden, which 
is almost too great for the strong to bear, while the 
weak and exhausted must succumb beneath the load, 
though the latter be no more than just sufficient to 
equip its possessor for a fair chance in the struggle 
for existence. 

It has been proved, however, that hard study can 
be borne with impunity provided that sufficient physi- 
cal exercise be taken. This is a truth which the liter- 
ary man and the student should ever have in mind. 
We have a good instance of this in the life of the late 
Frenchman, Littre, one of the most indefatigable 
literary workers of this age. His habit was to spend 
most of the day out of doors in physical recreation 
and exercise; and he only began his studies and his 
writing about seven o'clock in the evening when he 
would enter his library and pore over his books, ab- 
sorbed in study, or bend over his writing desk, work- 
ing without cessation, till three or four o'clock in the 
morning, when, yielding to fatigue, he would seek a 
few hours' refreshing sleep. 

In a recent spirited publication, Mary Mana- 



— 35 — 
•ceine * has traced the causes, effects, and remedies of 
mental over-pressure in modern life. She lays great 
stress on the want of gymnastic training in schools, 
and the numerous unhealthy conditions of our civiliza- 
tion. The besetting infirmities of the age are " cere- 
bral anaemia " and " nervous exhaustion." The causes 
are complex, but they all act similarly, " by producing 
irregularities in the vascular sphere," i. <?., by impair- 
ing the tonus of the cerebral blood-vessels. " When 
■once the tone of the blood-vessels is lost, when their 
nutrition is disturbed and the circulation no longer 
responds to the exigencies of normal life, phenomena 
of dissolution begin to manifest themselves." Doubt- 
less Mile. Manaceine is right in regarding the stimu- 
lants (tea, coffee, alcohol, tobacco, etc.) in which the 
people of this age are prone to indulge as being large 
factors in producing a toneless condition of the cere- 
bral vessels, but exhaustion by overwork, and especi- 
ally by worry, are doubtless still more important 
factors. 

With regard to the influence of physical over- 
work in producing insomnia, the explanation may not 
be so easy. A state of great physical fatigue is cer- 
tainly favorable to sleep, but over-fatigue is attended 
with a painful aching of the muscles, which causes an 
excitation of the cerebrum. Germain See adds as a 
factor the accumulation of the products of denu- 



*" Le Surmenage Mentale dans le Civilisation Moderne," 
Paris, 1890. 



- 36 - 
trition, which being in excess in the blood, act as 
toxic agents and excite the cerebrum. 

With regard to the treatment of insomnia by- 
mental overwork, the indicatio causalis first demands 
attention. The student must curtail his studies, his 
hours of work; must be content with a less honorable 
standing in his classes, must take more rest, more 
recreation, more exercise. These injunctions are 
especially imperative when the subject of insomnia 
is a growing youth; in fact, the appearance of 
insomnia, or dreamy, restless, unrefreshing sleep in 
children should generally be the signal for removing 
them for a time from school and prescribing suitable 
sports and recreations, a course of gymnastics, and 
other measures calculated to invigorate, subdue rest- 
lessness, and procure natural sleep. 

Dr. Dukes, of Rugby, is of the opinion that boys 
under ten years of age require eleven hours' sleep, 
and those under thirteen need ten hours and a half 
set apart for this purpose.* 

The same causal indications are applicable to 
the man of business, who, when once he finds himself 
unable to sleep of nights is on a downward scale, 
which will end in ruin unless he can pause and reform 
his habits. Even then he will realize the facilis 
descensus Avemi, while to retrace his steps — hie labor, 
hoc opus est. One of the most annoying forms of in- 
somnia among business men is this: The patient goes 



^Quoted by Macfarlane, he. cit. 



— 37 — 
to bed and falls asleep to wake up in an hour or two 
with his mind full of the care and worry of the day, 
and then there is no more sleep all night long; or if 
sleep returns after several hours of wakefulness, it is 
a disturbed, dreamy sleep from which he awakes 
tired, jaded, and miserable. This kind of insomnia is 
called by Germain See true insomnia. 

The following table is modified by Macfarlane 
from Friedlander, and contains his views as to the 
best division to be made of the twenty-four hours in 
the matter of rest, work, and sleep : 





HOURS FOR 














Exercise. 


Work. 


Leisure. 


Sleep. 


7 


7 


3 


4 


IO 


8 


6 


4 


4 


IO 


9 


5 


5 


4 


IO 


IO 


5 


6 


4 


9 


ii 


5 


6 


4 


9 


12 


5 


6 


4 


9 


13 


4 


7 


4 


9 


14 


4 


8 


3 


9 


15 


4 


8 


3 


9 



Besides making the endeavor to pursue a course 
of life the reverse of that which he has been pursuing, 
the victim of insomnia from overwork will naturally 
for a time seek relief from some of the safer hypnot- 
ics, preeminently among which is sulphonal. From 



- 38 - 
my own experience, I would say that sulphonal is the 
king of hypnotics, conferring a sleep which is the 
most like natural sleep with the least after-discomfort. 
Nor does the continued use of this drug seem to be 
attended with real harm — at least with any such evils 
as follow the prolonged use of morphine or chloral. 
I know one business man who has been in the habit 
of taking ten grains of sulphonal every night for six 
months, nor has he yet found it necessary to increase 
the dose. 

Chloral was formerly regarded as the ideal hyp- 
notic, and in many cases it produces a sound refresh- 
ing sleep of several hours. The late Dr. J. R. 
Nichols, of Haverhill, told me in 1873 that chloral 
had been a boon to him — that one dose of ten grains 
taken at bed time would quite banish his insomnia 
for a whole week, the effect not wearing away for 
several nights. 

In 'comparatively tractable cases of insomnia 
from overwork, a tablespoonful or two of old whisky 
at bed time will often work like a charm; sleep 
speedily ensues and lasts many hours; with many, a 
glass of bitter ale has a still better effect. 

As natural sleep may be hypothetically regarded 
as brought about by certain toxic products of exercise,, 
and as muscular exercise is known to be more pro- 
ductive of these hypnogenous substances than intel- 
lectual, so the medical adviser may very properly urge 
his patient to perform some severe muscular work 



— 39 — 
before going to bed — a long walk in the open air, 
dumb-bell exercise, etc. Many a victim of insomnia 
has found a remedy for his' infirmity in garden work, 
joinery, wood-sawing, or even in such active sports 
as base-ball and lawn-tennis. Sleep is much more 
certain to follow muscle-tire than brain-tire. 

As the leading indication is to induce that cere- 
bral torpor which is the necessary antecedent of sleep, 
it is well to advise the insomnic patient to avoid all 
cerebral excitants in the evening. He should not in- 
dulge in tea, coffee, tobacco or spirits, with the excep- 
tion, perhaps, of an occasional draught of old whisky on 
going to bed, as above stated; he should refrain from 
reading, writing, and other mental labor. Even novel 
reading (recommended by some as a diversion) is of 
questionable utility; listening to the reading of a dull 
book is a much more rational expedient. If one can 
succeed in breaking the train of thought by fixing the 
attention on any series of monotonous sounds (the 
singing of crickets, the roar of a distant waterfall, the 
whistling of the wind down the^chimney, etc.), he will 
often before he is aware of it be caught in the toils of 
Somnus. 

The sleep state being one in which the cerebral 
arterioles are contracted, with lessened circulation in 
the encephalon, the artificial production of this con- 
dition would seem to be favorable to sleep, and much 
account has been. made of cold applications to the 
head made with the intent to exsanguinate the brain; 



— 4 o — 

hot foot baths to determine blood from the head, and 
the general warm bath as a powerful means of deriva- 
tion. Hammond states that he has seen the applica- 
tion of the cold douche to the heads of refractory- 
prisoners bring on a deep sleep. I believe, however, 
that cold to the head, as a means of provoking sleep, 
oftener fails than succeeds, and I have even known it 
to aggravate the insomnia. Of more efficacy is bath- 
ing the trunk and limbs with cold water, followed by 
a brisk rubbing to induce a reactionary glow; stand- 
ing naked on the cold floor a few minutes, then a 
hasty rub-down with a coarse towel or flesh-brush, 
often does good in the same way by derivation. The 
warm bath or wet-pack may be resorted to in desper- 
ate cases. 

Macfarlane gives some excellent hints for the 
rational treatment of this kind of insomnia. To re- 
store tone to the vaso-motor system, he advises a 
combination of nux vomica with hydrobromic acid. 

IJ Acid hydrobromic 3 vi. 

Tinct. nucis vom 3 ii. 

Aquam ad. § vi. 

M. Sig. — A tablespoonful in a wineglassful of water 
twice a day, before meals. 

To calm and strengthen the nervous centres, the 
patient should cultivate the habit of going to bed at 
a regular hour, and of rising with punctuality. The 
bed-room should be well ventilated, and the head 
raised upon a high pillow. The hours for eating and 



— 41 — 
drinking must be laid down with precision, the diet 
being adapted to the temperament and digestive 
powers, the last meal being taken some three hours 
before going to bed. The plethoric, whose vascular 
tension is high, do best without alcohol in any form, 
while the anaemic are often benefited by a moderate 
quantity taken with the food to promote digestion 
and a "night-cap" of brandy or whisky with warm 
water and sugar. On account of its stimulant and 
derivative action, turpentine in thirty-drop doses at 
bed-time is a powerful aid to sleep. It is easily taken 
in capsules. If it is found necessary to resort to 
hypnotics, the bromides are especially serviceable, the 
only contra-indication being great ansemia. Mac- 
farlane prefers the bromide of lithium, as it contains 
a half more bromine than the potassium bromide. Its 
•dose is from 10 to 20 grains. The bromides of so- 
dium and potassium, which are in most frequent use 
in this country, are given in doses of one-half to one 
drachm. They are best prescribed in syrup and 
water, a full dose being taken a few hours before 
bed-time and another at bed-time. If these doses do 
not succeed ia procuring sleep, they may be asso- 
ciated with ergot of rye and digitalis, both of which 
are stimulants of the vaso-motor centres. Macfar- 
. lane's favorite prescription is as follows:* 



*Macfarlane, Inspmnia and its Therapeutics, page 88. 



— 42 — 

5 Bromidi lithii gr. xl. 

Ext. ergot liquid 3 i. 

Tinct. digitalis TUxx. 

Aquse chloroformi 3 xv, 

M. Sig, — Take one-half two hours before going to bed 
and the other half at bed-time. 

3. To the third group belongs insomnia con- 
nected with a disordered state of one or more organs. 

{a) Morbid States of the Brain. — These cause 
insomnia by interfering with cerebral nutrition. The 
changes taking place in the brain during cerebral 
hyperemia are more of a katabolic than of an anabo- 
lic character, i.e, are characterized by excessive waste 
rather than normal repair, hence are antagonistic to 
conditions which produce sleep. This hypersemia 
may be active or passive. Active hypersemia is due 
to overwork of brain (see preceding paragraph), to 
alcohol or other toxic agents, to arterial degeneration,, 
to exposure to intense heat, the irritation of teething,. 
to tubercles, syphilis, etc. The passive kind is gene- 
rally due to organic diseases of the heart and lungs.. 
Active cerebral hypersemia is characterized by flush- 
ing of the face, throbbing of the temporals, conges- 
tion of the retina, suffusion of the conjunctiva, irrita- 
tability, restlessness, giddiness, confusion of ideas, 
loss of memory, etc. In passive congestion, stupor is. 
the most marked symptom. 

In the active form, the indication is to lessen the 
quantity of blood in the brain; in the passive form, to 
increase the force of the circulation and lessen the 



— 43 — 
venous supply. The first indication is fulfilled by 
cold to the head, saline purgatives, leeches to the 
temples or outside the nose, mustard to the epigas- 
trium, the constant galvanic current for two minutes — 
the positive pole being over the sympathetic, the nega- 
tive on the nucha (Hammond). In this form of in- 
somnia, it is necessary to prescribe the bromides, or, 
these failing, chloral. In the passive kind, diuretics, 
saline purgatives, and opiates rather than bromides 
are called for. 

Alcohol, which is contra-indicated in active, is of 
great use in passive hyperemia. 

The cerebral hyperemia with which we are most 
familiar either soon ends in recovery — the patient 
gving up his severe tasks or his excesses in eating and 
drinking, and living more rationally — or it is the avant 
coureur of some severe and generally incurable brain 
affection. I have seen children suffer from flushed, 
hot head, vertigo, headache, irritability, peevishness 
{i.e., the symptom — cortege of hyperemia) for weeks 
before becoming the victims of hydrocephalus. I 
have seen it the precursor of apoplexy in the aged, 
being the first manifestation of atheromatous degene- 
ration. It may be the first symptom of general 
paralysis of the insane (periencephalitis). 

If simple hyperemia be inimical to sleep, a fortiori 
inflammatory states of the cerebrum or its membranes 
must be so. The insomnia of acute meningitis, of 
periencephalitis, of cerebritis, is sufficiently familiar, 



— 44 — 
and even when the usual restlessness, agitation 
and delirium give place to the .quiescence of coma, 
it is the repose of paralysis and death, rather than 
refreshing sleep, that is witnessed. 

In tuberculous meningitis, among the first symp- 
toms of the hyperaemia which precedes the developed 
disease, is a restless, dreamy sleep, which next gives 
place to complete insomnia. 

In the treatment of sleeplessness due to inflam- 
matory conditions of the cerebrum, the general prin- 
ciples laid down under cerebral hyperaemia are to be 
carried out. Full doses of chloral with bromides 
sometimes give brief seasons of quiet, if not product- 
ive of real sleep. I have found a combination of 
sulphonal with antipyrin more or less efficacious in 
the restlessness and delirium of meningitis. 

5 Sulphonal , 

Antipyrin aa gr. x. 

M. Sig. — One powder. To be repeated every hour till 
sleep or quiet is produced. 

This combination is especially indicated in 
hyperpyrexia. 

Cerebral tumors are a cause of sleeplessness, both 
from the inflammation which they excite and the pain 
which is a constant attendant. 

Anaemia of the brain, whether produced by ex- 
cessive loss of blood, profuse discharges from the 
intestines, from chronic abscesses, etc., by insufficient 
food, by exhausting diseases or other causes, gives 



— 45 — 
rise to sleeplessness or imperfect, dreamy sleep. The 
explanation of this insomnia is that in the anaemic 
there is not only an exsanguinous state of the brain, 
but a vice of nutrition resulting from insufficiency of 
arterial blood. Germain See adds another cause 
which applies to certain cases; the local oligaemias 
are generally due to emboli or obliterations of arteri- 
oles, and the failure of nutrition goes on rapidly to 
ramollissement, the initial symptoms of which are 
always those of excitation. 

The following case illustrates the general treatment of 
sleeplessness due to anaemia: 

Mrs. M. B.; aged fifty; mother of eight children; con- 
sulted me in May, 1883, for a uterine trouble whose principal 
manifestation was excessive haemorrhages. I found her 
weak and anaemic, obliged to keep her bed the most of the 
time. The heart's action was feeble; there was a systolic 
(anaemic) bruit; exertion, excitement, even ordinary food, 
would often bring on palpitations; walking or an attempt to 
work caused breathlessness. The face was frequently 
flushed (paresis of the vaso-motorsl; there were ringing 
noises in the ears, flashes of light before the eyes, and 
other perversions of the special senses; it required but 
little exercise of the eyes to tire them — reading, sewing, etc., 
after a few minutes became painful. There was an almost 
constant headache, with mental enfeeblement, and inability 
to apply the mind more than a few minutes to any subject. 
The insomnia was marked. 

I found a uterine polypus to be the cause of the profuse 
haemorrhages; this I removed by an ecraseur, thus arresting 
the loss of blood, but Mrs. B. suffered for months from the 
anaemic symptoms just mentioned. The distressing insom- 



— 46 — 

nia would only yield to opiates with draughts of whisky 
or bitter ale. A hypodermic of morphine always gave most 
relief, but this was seldom resorted to through fear of forming 
the morphine habit. A mixture of equal parts of red laven- 
der and ammoniated tincture of valerian, dose a teaspoonful 
in water, often had a marked soothing effect. Chloral was 
avoided; when taken formerly while Mrs. B. was under the 
care of another physician it had always produced excitement 
rather than quiet. A cordial frequently prescribed consisted 
of compound tincture of lavender, one drachm; tincture of 
valerian, one drachm; deodorized laudanum, twenty drops; 
this was taken at bedtime. After a few weeks had gone by, 
I omitted opiates altogether, giving only the whisky or ale 
at night; this also was eventually abandoned, a little beef 
tea or fluid beef being given instead. A course of physical 
exercise had been commenced — walks, rides in the open air, 
parlor gymnastics which powerfully promoted natural sleep. 
Throughout the treatment, nutrients were administered day 
and night in as large quantities as could be assimilated; thus 
always between meals a cup of beef tea or of warm milk 
with bovinine was given; an egg-nog was taken the first 
thing in the morning and a cup of milk with Mellin's food 
and a spoonful of bovinine at midnight. Eventually the 
recovery was as complete as could be desired. 

I have on record numerous cases of a similar 
kind, where the distressing insomnia brought on by 
long-continued discharges has yielded to suppression 
of the cause and the plentiful administration of stim- 
ulants and nutrients. 

The cerebral anaemia accompanying aortic-val- 
vular disease finds expression in an obstinate insomnia, 
in frequent attacks of vertigo, in intellectual disturb- 
ances, and in a profound irritability which has been 



— 47 — 
described under the name of irritable weakness. A 
similar line of treatment to that above indicated is 
needed, but the main reliance must be in opium or 
hypodermic morphine, in alcoholic stimulants, and in 
nitro-glycerin. It is hard to draw the line between 
anaemia and passive congestion, but it must be re- 
membered that in aortic disease the brain is in- 
sufficiently supplied with arterial blood, and hence is 
anaemic. It matters not if the cerebral substance is 
charged with venous blood, unless the subject is sup- 
plied with plenty of arterial blood and there is a free 
■circulation, the condition of the cortical cells is none 
the less one of anaemia. 

(b) Degeneration of the cerebral arteries is a cause 
of haemorrhage or softening, and one of its common 
symptoms is troublesome dreaming or insomnia, 
though some cases are characterized by morbid som- 
nolence. Dreaming in advanced life is generally 
regarded as suggestive of pending apoplexy (Mac- 
farlane). In the treatment of this kind of insomnia, 
the general principles applicable to cerebral anaemia 
are to be observed. Macfarlane speaks well of a 
mixture of henbane and camphor, and of sumbul and 
hops,* and professes to have obtained good results 

*His formulae are as follows: 

5 Spts. chloroform § ss. 

Tinct. sumbul, § ss. 

Tinct. lupuli 3 i. 

M. Sig. — Two teaspoonfuls in water every hour till 
sleep is procured. 



- 4 8 - 

IJ Tinct. digitalis .* TTLxx, 

Tinct. sumbul 3 j. 

Tinct, lupuli § ij. 

Aquam ad § ij . 

M. Sig. — Take one-half at bedtime in water, and repeat 
in two hours if required. 

from sponging the nape of the neck with hot 
water and from the application of mustard plasters 
for a few minutes over the epigastric region or the 
upper part of the spine. 

[c) Hysteria, hypochondriasis, mania, melancholia, 
are affections due to disturbances of nutrition of the 
cerebral cortex. The limits of this treatise will not 
allow a separate consideration of each of these affec- 
tions, which belong to the category of neuroses rather 
than of organic diseases. Nor can we here discuss 
the general subject of insanity in its relation to in- 
somnia. 

The sleep in hysteria may not be materially lessened in 
amount, but it is often unrefreshing. The hysterical subject 
wakes in the morning with a sense of physical fatigue or of 
mental depression or irritability. Dr. Mary Putnam Jacobi 
gives us an ingenious explanation which is worth repro- 
ducing. 

In the nervous system, and especially the brain, the 
waste products do not pass directly into the capillaries, but. 
into the lymphatic sheaths surrounding the arteries. The 
circulation of the lymph current, and its passage from the 
perivascular to the sub-arachnoid spaces, is regulated by the 
pulsations of the brain or its variations in volume, by which 
the lymph spaces are rhythmically compressed. The brain 



— 49 — 
pulsation is composed of three factors: The arterial pulse 
wave, the respiratory wave, and the vascular wave. The 
respiratory wave results from the aspiration of venous blood 
from the brain during respiration and the obstruction to its 
flow during expiration. The vascular wave advances like a 
peristaltic movement, and consists in rhythmic contractions 
and dilatations of the arterioles, apart from the cardiac pulse 
and dependent on intermittent vaso-motor influences. This 
vascular wave is said by Buckhardt to be much more regu- 
lar during sleep than in the waking period and constitutes 
the principal motor mechanism for removing waste products 
through the lymphatic channels. If it be true that this vas- 
cular wave is of more importance in the lymph circulation 
in the brafn than either the pulse or respiratory wave, it is 
clear that any disorder of the vaso-motor centres which gov- 
ern it may greatly disturb the removal of waste products by 
interfering with the normal development of such a wave. 
If, for example, the normal intermittence of vaso-motor im- 
pulses becomes exchanged for a permanent tonus, the dia- 
stolic portion of the wave would disappear, and with it the 
swelling of the hemispheres by which the ventricles are com- 
pressed. There would remain the variations in volume due 
to the cardiac systole and diastole, but in sleep these are re- 
duced to a minimum. Hence in any person subjected to ab- 
normal vaso-motor irritations must exist an imperfect 
removal of waste products from the brain during sleep and 
therefore imperfect refreshment by the great restorer.* 

The above considerations are not to be regarded 
in the light of mere speculation, but are legitimate 
deductions from accurate 'experimental observations 
by Buckhardt and Meynert. The same causes of im- 
perfect sleep are doubtless more or less operative in 

* Hysteria and Brain Tumor, New York, 1888. 

4 BBB 



_ 5 o — 

neurasthenia, and in all forms of functional brain dis- 
ease. 

(d) It is but natural that such painful affections 
as spinal meningitis and myelitis, and locomotor ataxa 
in its acute stages and painful crises should cause 
sleeplessness, only allayed by benumbing the seat of 
pain with anodyne narcotics, and only removed by 
successfully combating the disease. 

Antipyrin, or acetanilid, in ten to fifteen grain 
doses, frequently repeated till its sedative action is ex- 
perienced, often has a charming effect in relieving 
pain, irritation, fever, and thus promoting sleep. No 
medicine probably has given so much relief in these 
forms of spinal disease as antipyrin, but the doses 
must be large and continuous. 

In one case of locomotor ataxia with lightning 
pains that came under my observation, acetanilid in 
doses of ten grains an hour never failed to subdue the 
pains in the course of a few hours, though the patient 
often became restive under the pain and demanded a 
hypodermic of morphine. 

INSOMNIA OF RESPIRATORY ORIGIN. 

Under this head we propose to consider chiefly 
dyspnoea and cough in their relation to insomnia. In 
acute diseases of the respiratory organs, pain and fever 
are influential along with other factors in the produc- 
tion of an insomnia which naturally yields when the 
acuteness of the disease subsides. In pleurisy and 



— 5i — 

even in pneumonia the pain may be severe enough to 
require an opiate, and even a hypodermic of mor- 
phine; with regard to pneumonia, I think that we 
should be chary in the use of opiates, no matter how 
severe the cough or the pain may be. This I say from 
experience, without formulating any theory in explana- 
tion. I know that the pain of this disease often yields 
to a sinapism or hot poultice, to a full dose of quinine 
with extract of aconite, and to repeated full doses of 
veratrum viride. My friend, Dr. B. W. Bartlett, of 
Rowley, has great faith in the application of a dozen 
leeches to the chest in the onset of pneumonia, with 
hot water fomentations prolonged for hours after- 
wards; the pains are alleviated and rest promoted 
without the assistance of any anodyne. 

The dyspnoea of respiratory disease (apart from 
cardiac complications) is either spasmodic or obstruc- 
tive. Spasmodic dyspnoea is exemplified in false 
croup, in bronchial asthma, and in true asthma. In 
all the bronchial affections of children a neurosal 
element can be clearly traced; this is especially 
noticeable in the paroxysmal cough and dyspnoea of 
whooping-cough. 

Respiratory dyspnoea when not due to spasm 
may be the result of obstruction: a, by exudation 
within the pulmonary parenchyma as in pneumonia; 
I, by exudation within the pleural cavity (pleurisy) ; c, 
by swelling of the bronchi and profuse bronchial secre- 
tion (acute bronchitis, especially capillary bronchitis). 



— 52 — 
The treatment of insomnia from any of the above 
conditions resolves itself into the endeavor, as far as 
possible, to alleviate or. remove the cause. Bronchitis 
should be treated in the earlier stages by medicines 
which allay febrile excitement, vaso-constriction and 
spasm, in short, by remedies which diminish the peri- 
pheral resistances. Among these, I think, antimonials,* 
ipecacuanha, veratrum viride, and lobelia inflata still 
hold the first place. 

IJ Antimon. et. pot. tart gr. j. 

Nitrate of potassium 3 j. 

Mucilage vel. aquae § vj. 

M. Sig. A tablespoonful every two hours. 

^ Vin. ipecac 3 ij. 

Mucilage § vj. 

M. Sig. A tablespoonful every two hours. 

IJ Fluid ext. verat virid 3 ss. 

Aquae § ij. 

M. Sig. A teaspoonful every hour or two. 

When the bronchial secretion is well established, 
the antimonial and other depressant may be omitted 
and carbonate of ammonia substituted in five grain 
doses. A small dose of chloral may be admissible at 
bed time; when the secretion is very profuse an 
emetic of sulphate of zinc or turpeth mineral may be 
given as Macfarlane recommends. After the tubes 

*The combination of tartar emetic and morphine, ■£$ 
grain every hour till the oppressive cough ceases, is one to 
which I have often had occasion to resort. 



— 53 — 

are emptied, a dose of urethan (gr. xxx) of paralde- 
hyd (3j.)> or even a Dover's powder (gr. x) may 
be administered. 

The general principles of treatment of neurosal 
dyspnoea are the same, whatever name may be appli- 
cable to the particular manifestation. Antispasmodics 
and anaesthetics are always indicated; in attacks of 
spasmodic asthma and laryngismus stridulus, a few 
drops of the anaesthetic mixture A. C. E., inhaled 
from a sponge or towel, always give relief. 

5 Alcohol i part. 

Chloroform 2 parts. 

Ether 3 parts. 

Mix. 

Nitrate of amyl, gtt. iii, inhaled from the palm 
of the hand frequently gives instant relief; chloral 
hydrate with potassium bromide in full doses is slower 
in its action, but more permanently reduces inordi 
nate reflex excitability. With some patients hypo- 
dermic morphia is a necessity. In laryngismus stridu- 
lus or spurious croup an emetic is generally sufficient 
speedily to relax the spasmodically tightened air- 
tubes. Of all emetics the turpeth mineral is the one 
which in my practice has yielded the most satisfactory 
results. Parke, Davis & Co. make tablets of this salt 
containing two grains, which are very convenient. 

A more frequent cause of insomnia is cough. 

I have not space to review the various pathologi- 
cal conditions productive of cough and supplement 



— 54 — 
such review by therapeutical hints. The most that I 
can do is to touch upon a few points of practical im- 
portance in connection with the relation of insomnia 
to cough. 

In the early stages of consumption, the patient 
may be tormented with a teasing cough which is for 
the most part dry. Every physician is familiar with 
such cases. The physical signs are obscure; at the 
most there is a slight dulness under one or both clavi- 
cles, but there is a little febrile movement every day 
with failure of appetite and strength. This cough 
indicates an irritation of the respiratory organs by 
bacilli and tubercles, and is not alleviated by the 
ordinary expectorants. Here calmatives and seda- 
tives with counter irritation do little or no good. A 
pill of codeia, one grain, at bedtime will sometimes 
effectively allay irritation and produce sleep. Chloral, 
bromide of potassium, cannabis Indica, hyoscyamus 
and belladonna may all be tried, with doubtless some 
alleviation at first; while nothing will so promptly 
relieve and so thoroughly as morphine. The latter 
medicament may be combined with dilute hydrocyanic 
acid, chloroform, and tolu, as follows: 

IJ Chloroform gtt. xvj. 

Morph. sulph gr. ij. 

Acid hydrocyanic, dilute gtt. xxj. 

Syrup tolu % ij. 

M. Sig. — A teaspoonful at bedtime and at midnight 
when the cough is troublesome. 



— 55 — 
A spray of liquid albolene and menthol used by 
a hand atomizer will sometimes allay the tickling in 
the upper air passages which seems to be the point of 
departure of the cough. 

1$ Liquid vaseline § j. 

Menthol , 3 ss. 

M. For the spray-producer, 

Such patients are often benefited by full doses of 
" Rock and Rye " on going to bed. 

I have seen good results from small blisters ap- 
plied to the upper part of the chest, or from painting 
the upper thorax with tincture of iodine till the skin 
begins to peel. 

Of the various cough troches, there is one made 
by Parke, Davis & Co. and other of the pharmacists, 
containing a little cubebs with extract of licorice, 
which has given satisfaction in my practice. I have 
seen somewhere the advice to paint the throat with 
liquor cocaine; this expedient I have never tried, but 
I should think that it might produce some temporary 
alleviation. 

In the later stages of phthisis when expectora- 
tion is profuse, it is not always safe to arrest the 
cough by narcotics given at bed-time; there is so 
much secretion from the vomicae and inflamed mucous 
membrane that frequent fits of coughing are neces- 
sary to remove muco-pus and prevent asphyxia. In 
such cases an emetic of sulphate of zinc sometimes 



-56 - 
has a salutary effect in clearing the bronchi and per- 
mitting a few hours' quiet sleep. I have found bella- 
donna serviceable in restraining secretion; this may- 
be prescribed in the form of a pill of atropine, y^-th 
grain, night and morning. Senega, turpentine, tar, 
sulphur, and carbonate of ammonia have a reputation 
when there is copious expectoration, and the spray of 
ipecacuanha wine, as recommended by Murrel, may 
be tried to advantage. 

The syrup of tar, with carbonate of ammonia, 
and the Compound Pine Expectorant of P., D. & Co., 
are preparations which have become popular. 

The catarrh is a product of bronchial congestion 
provoked and kept up by the presence of tubercles, 
and cannot be much modified while active tuberculiza- 
tion exists. 

In the teasing, paroxysmal cough of pertussis, 
full doses of antipyrin or acetanilid have proved of 
great efficacy. 

5 Acetanilid 3 ss. 

Divide in chart, No. vi. 

Sig. Give one powder every four hours night and day, 
and keep up the treatment for a week or even a fortnight. 

For a child of io years, the five-grain tablets are 
very convenient. The one-grain tablets (one every 4 
hours) may be prescribed for infants. 

Antipyrin, phenacetin, or exalgin in equivalent 
doses may be given instead of acetanilid. I have 
given infants two years old grain doses of antipyrin 



— 57 — 
every two hours in whooping-cough, and seen the 
paroxysms markedly diminish in frequency and 
violence under this treatment. The quantity of either 
antipyrin or acetanilid may be increased, if necessary, 
till a decided constitutional impression is produced. 

I used to give bromide of potassium in whoop- 
ing-cough, with or without chloral, and have seen 
marked mitigation of the paroxysms thereby pro- 
duced. 

5 Pot. bromid ... 3 i j - 

Hyd. chloral 3 ss. 

Syr. tolu 1 iij. 

M. Sig. A teaspoonful every hour till sleep is pro- 
duced. For a child 5 years old. 

THE INSOMNIA OF HEART DISEASE AND ITS TREAT- 
MENT. 

In aortic disease (constriction, insufficiency, 
aortitis, aneurism) the arterial outflow is embarrassed, 
and unless the compensatory hypertrophy be sufficient 
through the extra power thereby given to the heart- 
muscle to ensure filling of the arteries, the whole 
organism suffers in its nutrition and function, and no 
department more than the • cerebrum. Hence, the 
insomnia of aortic disease is essentially the insomnia 
of anaemia. 

But there is generally more than this. The 
blood-depurating organs participate in the general 
disturbance of nutrition, and imperfectly eliminate 
waste elements, and to the poverty of arterial blood 



— 5 s — 
in the system is added a more or less toxic condition 
of the blood. 

Now that we are better acquainted with the con- 
ditions productive of aortic affections, we know that 
the latter are very often the expression of that wide- 
spread disease of the arteries, arterio-sclerosis; the 
victim of heart disease has interstitial nephritis, and,, 
sooner or later, becomes anaemic. 

A peculiar state of mental irritability generally 
accompanies aortic disease, and may even give rise to 
a form of insanity. 

Among the symptoms of aortic disease are par- 
oxysmal crises of dyspnoea (cardiac asthma), especi- 
ally frequent at night, and attacks of precordial pain, 
which arrest the patient in his occupation; if he is- 
walking, compel him to stop and lean against some 
support. 

The pain in the earlier stages of aortic disease is 
characterized by momentary pangs, and is the result 
of exertion; in extensive atheromatous disease of the 
aorta involving the coronary arteries, it is of a much 
more intense, prolonged, and agonizing kind, and is 
true angina pectoris. 

In the treatment of the insomnia of aortic dis- 
ease, the mechanism by which this insomnia is brought 
about must be kept in mind. A leading indication is 
to promote the arterial blood supply of the brain, and 
thus improve its languishing nutrition. The pure 
hypnotics, chloral, paraldehyd, sulphonal, are rarely" 



— 59 — 
useful, while there is one remedy which is of sovereign 
efficacy, which energizes the circulation and relieves 
dyspnoea and pain. "Opium," says Gabler, "deter- 
mines a particular excitation, gives fullness to the 
pulse, raises the temperature, augments the injection 
of the teguments and promotes diaphoresis. The 
countenance brightens, the eyes become brilliant and 
moist, the pupils contracted, the skin covered with 
perspiration, then quiet sleep ensues." 

The morphine may be associated with atropine 
and administered hypodermically, and for this pur- 
pose the compressed tablets (sulph. morph., % grain; 
sulph. atrop.ia, T | ¥ grain) are very useful. It may be 
necessary to resort to these injections very often — 
every day, with gradually increasing dose — and there 
will be the risk of rendering the patient a morphio- 
maniac, but it is a choice between two evils in an in- 
curable disease steadily becoming worse. 

As to the question of the applicability of digitalis 
in aortic disease, there is considerable difference of 
opinion. A weak, struggling heart always seems to 
demand this potent remedy, but practically it has not 
been found, at least in the earlier stages of aortic 
disease, to be so beneficial as nitro-glycerin and the 
vaso-dilators. The reason is probably this, as stated 
by Huchard: that the "cardio-aortic" patient is not 
only suffering from anaemia, but from a poisoned con- 
dition of the blood — the dyspnoea and the precordial 
anguish are often toxic, and are the expression of 



— 6o — 

spasmodic constriction of the arterioles, a condition 
which is favored by digitalis, whose tonic action ex- 
tends to the whole arterial system. Under the in- 
fluence of this drug, the arterioles are tightened 
rather than relaxed, while, on the contrary, nitrite of 
amyl and nitrite of soda, and especially nitro-glycerin 
systematically and perseveringly administered, relax 
the arterial system, thus inviting rather than opposing 
the sanguineous outflow, and lightening the work 
of the heart. To these remedies may be added 
an exclusive diet of milk, which by its nutrient pro- 
perties, its easy digestibility, its absence of toxic ex- 
tracts, and its marked diuretic action wonderfully 
promotes the comfort and well-being of these " cardio- 
arterial " subjects. 

The insomnia of mitral disease, as well as of a 
number of other forms of heart disease, is closely 
associated with the dyspnoea that attends those affec- 
tions, and this is a convenient place for a few more 
general considerations on cardiac dyspnoea and its 
treatment. 

CARDIAC DYSPNCEA. 

When we consider the frequent coincidence of 
cardiac lesions with dyspnoea, we cannot regard it as 
surprising that in the infancy of pathological anatomy 
Rostan, noticing in a large number of aged patients 
at the Saltpetriere, recorded as asthmatic, definite 
lesions of the heart and aorta, should have concluded 
that asthma, as an idiopathic malady, does not exist, 



— 6i — 

being always symptomatic of diseases of the circula- 
tory organs. 

When we inquire into the conditions of cardiac 
dyspnoea, we find them to be: Mitral stenosis and in- 
sufficiency; myocarditis and fatty degeneration of the 
heart-muscle; dilatation of the ventricles and aorta, 
from whatever cause; and uncompensated lesions of 
the valves of the aorta and pulmonary artery. 

In the case of most of the above causes, the 
modus agendi is very simple; the dyspnoea is of 
mechanical origin, being the result of pulmonary 
stasis; the heart is unable to clear the capillaries in 
the sphere of the lesser circulation. 

Most persons affected with mitral disease are 
short-breathed; when at rest they have little or no 
dyspnoea, but they immediately suffer for want of 
breath when they attempt any considerable exertion, 
as going up a flight of stairs or ascending a hill. In 
the earliest stages of mitral insufficiency the dyspnoea 
may be hardly noticed, except when the heart is 
severely taxed, as in the effort of running; in advanced 
stages the difficult breathing becomes permanent on 
account of the constant pulmonary engorgement. 
There is nothing asthmatic about this, for the essen- 
tial characteristic of asthma is the intermittent and 
paroxysmal character of the dyspnoea. 

The difficult breathing attending aortic-regurgi- 
tant disease, aortitis, dilatation of the heart cavities 
and aorta, fatty degeneration, etc., is generally parox- 



— 62 — 

ysmal in its nature, and the attacks come on in the 
night time rather than in the day. The explanation 
given by Professor See was formerly regarded as sat- 
isfactory: "The blood-stasis in the lungs, which is 
the first cause of the oppression, manifests itself gen- 
erally in the night time, because it is favored by de- 
clivity, that is, by the dorsal decubitus; to this first 
cause are added others which contribute much toward 
provoking the explosion of those attacks of respira- 
tory distress which often present a formidable inten- 
sity. These purely mechanical causes are: Disten- 
sion of the stomach, and the forcing upward of the dia- 
phragm, which notably diminish the respiratory area, 
already insufficient for hsematosis. Add, as accessory 
causes, bronchial catarrh and frequent concomitant 
emphysema, and you have the entire aetiology of par- 
oxysmal dyspnoea linked to affections of the heart." * 

The dyspnoea due to dilatation of the heart, ac- 
cording to Professor See, is almost always continuous, 
though there are paroxysmal exacerbations, and that 
due to fatty degeneration is sui generis, " presenting 
sometimes real paroxysms of distress and suffocation 
at the same time that careful examination of the 
lungs does not reveal any morbid signs; there is not. 
the least acceleration of the breathing, or any appar- 
ent impediment to respiration." 

Irritation of the cardiac and respiratory plexuses 



Maladies du Coeur, etc., 1883, p. 30. 



-6 3 - 

of nerves, as Peter, Trousseau, etc., teach, has been 
believed to have some share in the respiratory dis- 
tress; and the magical relief conferred by a hypodermic 
injection of morphine or other calmative before even 
the pulmonary congestion or oedema is mitigated, has 
been cited in confirmation of this doctrine. 

Henri Huchard has of late written much and 
lucidly on the paroxysmal dyspnoea of aortic regurgi- 
tation and aortitis. The dyspnoea of aortitis is, like 
that of mitral disease, at the first a dyspnoea of effort, 
coming on during rapid walking, lifting, etc.; it is 
paroxysmal and often intense, rarely spontaneous. 
Later on in the disease the attacks come on in the 
night time, often reproducing themselves with great 
regularity, so that the patient is obliged to pass the 
night in his arm-chair. Huchard regards this " aortic 
pseudo-asthma" as due to arterial hypertension which 
" augments by the recumbent posture and under the 
influence of sleep, as also by walking, and under the 
influence of movement." The cause of the dyspnoea 
is " mechanical," as Professor S£e taught, but not in 
the same sense as he taught, for in Huchard's view 
we have to do with " peripheral resistances," and 
" spasm " of the blood-vessels. If, says Huchard, 
distension of the stomach has anything to do with the 
paroxysmal dyspnoea, abstinence from the evening 
meal or a very frugal repast ought to keep the patient 
free from his nocturnal attack; this is, however, sure 
to come, whether he eat little or much. 



— 6 4 - 

This dyspnoea, Huchard affirms, is also of toxic 
origin. Experiments like the following seem to 
demonstrate this: He injects under the skin of a 
guinea-pig normal urine; death ensues in several 
days. He injects the same quantity of urine from a 
woman affected with arterio-sclerosis of the heart and 
aorta, and the guinea-pig scarcely suffers any detri- 
ment. This proves, he says, that the blood of his 
patient was poisoned by the products of disassimilar 
tion which the kidneys, already impermeable by the 
fact of the aortitis and a commencing arterio-sclero- 
sis, could but incompletely eliminate. These views, 
he urges, are not simply theoretical, they are con- 
firmed by practice. In fact, blood-letting, purgatives, 
nitrite of amyl, nitro-glycerin, etc., which depress 
arterial tension, contribute in large measure to dimin- 
ish the intensity of the attacks. But nothing works- 
so well as an exclusive milk diet, which acts marvel- 
ously in combating these attacks of aortic dyspnoea, 
often keeping them completely in abeyance. Now 
milk diet, according to Huchard, acts in two ways 
and meets two indications: First, by the abundant 
diuresis which it provokes, the milk diminishes the 
arterial tension and promptly eliminates the toxic 
principles contained in the blood; then it acts by vir- 
tue of its very harmlessness and because it does not 
contribute to the blood in circulation, like other ali- 
ments, and meat in particular, materials which, not 
being completely eliminated, become rapidly toxic to 
the economy. 



- 65 - 

INSOMNIA OF GASTRO-INTESTINAL ORIGIN. 

Writers have dwelt much on the cerebral hyper- 
emia attending disordered states of the stomach. 
That indigestion causes insomnia by exciting the 
cerebrum is a matter of common experience. With 
many persons, even, the active exercise of digestion, 
if this be at all difficult, is incompatible with sound 
sleep. Such individuals refrain from lunching or par- 
taking of a hearty meal before going to bed. Certain 
valetudinarians cannot drink a glass of milk or eat a 
biscuit late in the evening without atoning for the 
indiscretion by hours of sleeplessness. 

Such inhibition of the cerebrum by the stomach 
is of frequent experience in the nursery. The first 
thing the physician thinks of when consulted with 
reference to insomnia in a young child is the proba- 
bility of indigestion as the main factor in the case. 
What is the quality of the food, what about the quan- 
tity, and what is the condition of the digestive organs ? 
Attention to these points, in the absence of objective 
signs of importance, as fever, will generally put one 
on the track of the cause and suggest the remedy. 

The indigestion may be functional or organic, 
and all pathological conditions of the stomach are 
likely to be accompanied by insomnia. Structural 
diseases, as gastritis, ulcer, gastrectasis, cancer, cause 
sleeplessness, both by the pain and discomfort, and 
the consequences of indigestion which attend them. 



— 66 — 

One of the most frequent symptoms of indigestion is 
flatulence. The stomach, by failure of the normal 
peptonization process, is inflated and oppressed by 
the gases of decomposition; the distended stomach 
presses on the thoracic organs, embarrassing the 
heart and causing troublesome palpitations. Toxic 
products are often formed by the mal-elaboration of 
peptones; these irritate the nervous centres and 
render the cerebrum hyperemia 

But there is another aspect of the question. In 
persons with healthy stomachs and normal arterial 
tone, the digestive process is not prejudicial to sleep. 
Somnolence, in fact, often attends digestion, espe- 
cially after a hearty meal. This has been attributed 
to the flushing of the stomach — at the expense of the 
cerebrum— which is a necessary condition of its func- 
tion. Digestion normally occurs without attracting 
the consciousness, and there is no reason why on 
proper occasions sleep should not follow a hearty 
meal in men as well as in carnivorous animals. It is 
not true that during sleep the digestive functions are 
practically suspended, as some authorities have said: 
" During sleep the medullary centres relax their act- 
ivity, digestive fluids are not secreted, and the move- 
ments of the gastro- intestinal canal almost, if not 
entirely, cease."* It is surprising to meet with an 
error of this kind in a writer ordinarily so accurate as 



* Insomnia and its Therapeutics, p. 192. 



- 6 7 - 

Macfarlane. The stomach and intestines continue 
their function during sleep, though with lessened act- 
ivity; the secretions are not suspended, the unstriped 
muscular fibre continues a constant though dimin- 
ished action; the spinal cord even seems preternatur- 
ally active, the inhibiting restraint of the cerebrum 
being withdrawn. In reality, in sleep all the essential 
functions continue to be exercised. Those most 
indispensable to life, circulation, respiration, diges- 
tion, etc., are performed as during the waking. period, 
though more sluggishly. Thus, the heart beats more 
slowly during sleep. " Pulsus in somno parvi, lan- 
guidly rari" says Galen. With the retardation of the 
circulation, there is diminished activity of the secret- 
ing glands (gastric, intestinal, pancreatic, etc.), but in 
healthy persons these organs are adequate to the work 
imposed upon them, as is proved by the fact that mul- 
titudes can eat a full meal* on going to bed, sleep 
soundly, and be ready for another meal on awaking. 
Nor can it be said that the peristalsis of the gastro- 
intestinal canal ceases during sleep, any more than 
the contraction of other unstriped muscles (the arteri- 
oles, for instance), which are not under the will. 

Germain See, who refers most cases of digestive 
insomnia to difficulties attending the secondary or in- 
testinal digestion (and here he is seconded by Macfar- 
lane) thus defines this kind of insomnia: " Intestinal 
digestion generally begins three hours after a meal 
and ends in seven or eight hours. The patient, we 



— 68 — 

will suppose, sups at 6 o'clock p.m. At 10 o'clock he 
goes to bed, but cannot sleep till long after midnight. 
This is the time when the pancreatic-intestinal diges- 
tion is going on; when this is finished, the patient 
goes to sleep. 

" To prove that I am right as to the cause of the 
insomnia, let the patient eat a light supper at the 
usual time, or let him sup at 4 o'clock in the after- 
noon, and he will find that he will go to sleep at the 
proper time."* 

In the treatment of insomnia from indigestion, 
the quantity and quality of the food must be taken 
into account, the conditions of the stomach, intes- 
tines, and the auxiliary organs. 

(1) Errors are most frequently committed as to 
quantity. The digestive organs may be competent to 
dispose of a certain bulk without pain or difficulty, 
while an excess causes ambarrassment to the stomach; 
decomposition and flatulence set in under unmolested 
microbic rule; putrid and more or less toxic gases 
and ptomaines are generated, and a "bilious" condi- 
tion supervenes, such as every one has experienced at 
times. It is doubtless true that while multitudes are 
underfed, more persons are injured by excessive eat- 
ing than by a spare diet. Insomnia naturally comes 
in as one of the consequences of over-eating and over- 
drinking, for a burdened stomach will not let the 
brain rest. 



Des Dyspepsies, etc. Second edition. Paris, 1883. 



- 69 - 

The proper remedy for sleeplessness arising from 
this cause is apparent; it is to curtail the daily rations 
to the physiological standard. The necessity of eat- 
ing slowly and deliberately with thorough mastication 
of the food, is apparent; those that "bolt " their food 
are sure to eat to excess. 

(2) Food of poor or insufficient quality produces 
anaemia and starvation of vital organs, including the 
cerebrum, and hence engenders insomnia. Physicians 
cannot too much insist on the necessity of a full diet, 
that is, of an adequate admixture in the daily fare of 
albuminoids, fats, and carbo-hydrates. Food of in- 
digestible quality produces essentially the same evils 
as excessive alimentation. Under this head may be 
included food improperly or insufficiently cooked 
(good cookery under our civilization has become in- 
dispensable to healthy digestion), and foods that 
most persons of sedentary habits find hard to digest, 
as unripe fruit, pastries, hot bread, fried pork, confec- 
tionery, Of course, butcher's meats should be selected 
that are tender and juicy, and in the light of recent 
discoveries (Gautier, Selmi, etc.), it is doubtful if 
meat or game that has become high (faisande) is fit 
for food. 

Foods of themselves sufficiently digestible may 
become indigestible if too many kinds are eaten at a 
meal. But this brings us again to the evils of excess- 
ive eating. 

It need not be repeated that he who would sleep 



— 7o — 

well must avoid those articles of diet which have been 
found to be indigestible, or should indulge in them 
sparingly. Much depends, of course, on the muscular 
work done. Horace speaks of the dura ilia messorum. 
The hay-makers on the salt marshes need food hard 
of digestion, that is, food that is slowly digested, yield- 
ing up force for many hours; food that in common 
parlance "stays by," such as baked beans and pork, 
boiled beef and cabbage, and mince pie. Such per- 
sons sleep well, despite their hearty fare; it is especi- 
ally the " brain-workers," the men of sedentary habits 
that are upset by a rich diet. 

(3) A healthy digestion presupposes a healthy 
state of the stomach, intestines, and accessory organs,, 
and any derangement of these viscera must be cor- 
rected by suitable medicinal and dietetic means before 
normal sleep can be enjoyed. 

To enter on a consideration of all these derange- 
ments would take more space than we have at our 
command. The hygienic treatment of indigestion in- 
cludes dieting, exercise, recreation, cold bathing etc. 
The cold shower-bath in the morning is sometimes a 
powerful aid to digestion. Exercise promotes a more 
vigorous circulation and favors peristalsis and chymi- 
fication; equally necessary are change of scene, diver- 
sions, and the cultivation of a contented, cheerful 
frame of mind. 

Among the medicinal means are: 

(1) Such as favor gastric digestion, namely, alka- 



— 7i — 

lies before meals, and acids with pepsin, after. 
Clinical experience has proved pepsin to be of some 
value. Small doses of strychnine are useful. 

(2) For acid dyspepsia full doses of bicarbonate 
of soda are naturally indicated. Professor See ad- 
vises dyspeptics with excess of acid secretion to take 
a drachm of bicarbonate of soda in hot water on go- 
ing to bed. It is certain that in certain morbid states 
of the stomach and intestines, whether due to " hyper- 
chlorhydria " or to excess of mucus, the beneficial 
sedative effects of alkalies are pronounced. 

(3) Constipation is another recognized cause of 
insomnia, whether by the reflex irritation of retained 
excreta, or by the flatulence which frequently attends 
a loaded colon. Here the remedy is obvious; such 
laxatives as rhubarb, Glauber salts, cascara, enemata 
of hot water, etc. Persons who sleep poorly from 
this cause often find a hot water enema on going to 
bed a sovereign remedy. 

When that old bugbear, a torpid liver, is at fault 
(if this can be determined), of course a blue pill, a 
dose of enonymin or podophyllin would seem to be in- 
dicated. 

There is an acidity of the stomach which depends 
on abnormal acid ferments, the products of decompo- 
sition of starches or sugars in the food. In these 
cases, washing out the stomach by means of emetics 
and copious draughts of warm water every night for 
three or four nights, as Macfarlane recommends, 



— 72 — 

often proves very efficacious. The same writer ad- 
vises ferro-alumen in three-grain doses for pyrosis 
along with three drops of dilute hydrocyanic acid, and 
turpentine in ten-drop doses for flatulence, as most 
effective remedies. 

Gastralgia and gastrodynia demand anodynes 
and anti-spasmodics. In the experience of many 
authorities, a pill of opium, or an equivalent of the 
deodorized tincture is more efficient in gastralgia 
than morphine hypodermically or by mouth. 

In the treatment of gastric neurasthenia, the fol- 
lowing therapeutic regulations may be carried out: 

i. The patient may take with each meal 5 grains 
each of salicylate of bismuth, magnesia, and bicarbon- 
ate of sodium. 

2. He may take, on going to bed, a dessert- 
spoonful of compound licorice powder. 

3. Every day he may have a cold jet-douche of 
15 seconds' duration applied along the vertebral col- 
umn; energetic dry friction with a flesh-brush after 
the douche. 

4. Walks in the open air, muscular exercises 
(fencing, opposition gymnastics, etc.,) are beneficial. 

5. There should be only two meals a day, the 
one at 10 a.m. and the other at 7 p.m. The diet 
should consist chiefly of eggs, cereals, green veget- 
ables and fruits; the eggs to be nearly raw, the 
starchy foods and vegetables to be thoroughly 
cooked, the fruits to be stewed. Drinks to be water 



— 73 — 
•or a light white wine with ordinary water; no gaseous 
waters, no pure wine, no whiskey or other distilled 
liquors. Such patients often do best on a dry diet* 

Intestinal indigestion is to be treated mainly by 
dieting. The liquor pancreaticus has been recom- 
mended by some writers; it is doubtful if pancreatin 
•exercises any action outside of the stomach. Diar- 
rhoea and constipation are to be treated by the appro- 
priate remedies. 

Sleep, in this form of indigestion, is often im- 
proved by the nightly use of massage, and also by the 
application of a bag of hot water over the abdomen 
(Macfarlane). 

THE INSOMNIA OF CYSTITIS. 

Chronic cystitis produces obstinate and painful 
insomnia. This disease is a common consequence of 
enlarged prostate, calculus in the bladder, of gonor- 
rhoea, and stricture of the urethra. Micturition is 
frequent, and attended with scalding pain; the urine 
contains muco-pus, which adheres to the bottom of 
the vessel when turned upside down. 

Sleep is interfered with both by the pain (which 
in chronic cases may, however, be absent) and by the 
frequent calls to urinate. The victim of cystitis and 
prostatitis is obliged to get up every hour or two 



*Dujardin-Beaumetz, Therapeutic Gazette, January 
15th, 1890. 



— 74 — 
(sometimes every half hour) in the night to make- 
water, and the act of micturition is often attended 
with a tenesmus that is most distressing. 

The treatment should aim at removal of the 
cause. If there is a stricture or enlarged prostate or 
stone in the bladder, the proper measures should be- 
taken for their removal or relief. If the cause can- 
not be reached, recourse must be had to palliative 
remedies. Washing out the bladder every day, or 
twice a day, with warm water, to which some antisep- 
tic is added, as Marchand's peroxide of hydrogen, 
carbolic acid, boric acid, thymol, is now recommended 
by the best authorities, and certainly often gives 
marked relief. I have known patients, who had been 
long sufferers from prostatic disease which made 
their nights wearisome and life a burden, able to 
obtain several hours of quiet sleep after irrigating the- 
bladder with a little warm carbolic water. For this, 
purpose the soft rubber catheter is very useful. 
These are of various makes. The Jacques French 
catheter, the Tiedmann, the Davidson, are those with 
which I am best acquainted. The peculiar merit of 
these instruments is that they may safely be left to 
the patient to be passed by himself. The catheter is^ 
first greased with a -little eucalyptus vaseline and 
passed into the urethra, then carefully pushed along 
till the flow of urine by the distal end indicates that 
it is in the bladder. After emptying the bladder, the 
cannula of a little hand-ball syringe, which is filled 



— 75 — 
with the antiseptic solution, is introduced into the 
mouth of the catheter and the contents injected into 
the bladder; the solution is then allowed to run out, 
and more is injected till the water flows off clean and 
free from mucus. 

Too much pains cannot be taken to have the 
catheter always clean and aseptic; obstinate cystitis 
has been more than once started by the use of a foul 
catheter. 

Suppositories of morphia, of opium, of hyoscya- 
mus, etc., are often advantageous. The following 
prescription is frequently employed in the Jefferson 
Medical College Hospital of Philadelphia: 

I£ Pulv. opii gr. xij. 

Camphorae gr. xxx. 

Ext. belladonna gr. iij. 

Cacao q. s. 

M. et in suppos. No. vi, divide. 
S. One each night on retiring. 

A teaspoonful of the tincture of hyoscyamus at 
bedtime sometimes proves to be a useful hypnotic in 
cystitis. The ordinary hypnotics (chloral, sulphonal, 
paraldehyd, urethan) are of little or no benefit. 

INSOMNIA FROM GENITAL IRRITATION. 

In this connection it is necessary to allude 
to the insomnia which attends genital irritation. 
While excess in venery sometimes causes insomnia by 
impairing nervous tone, there is another frequent 



- 76 - 
cause in individuals otherwise healthy, viz., contin- 
ence. Every physician is now and then consulted by 
vigorous young men who have at some time given 
loose reins to their passions, and who afterwards in 
consequence of prolonged continence have trouble- 
some erections at night which waken them and keep 
them awake. In such cases, in the event of the 
physiological satisfaction of an imperative want being 
impracticable, recourse must be had to sedative medi- 
cines, to anaphrodisiacs. 

The suppository of camphor and opium (see 
above) may be given to advantage, or a full dose of 
chloral, or of bromide, has a great reputation in in- 
somnia due to genital irritation. It should be given 
in large doses and followed up for some time. 

5 Pot. bromide 3 iv. 

Tinct. hyoscyami § ss. 

Mist camph § vss. 

M. Sig. A tablespoonful three times a day and at 
bed time. 

Lupulin, which may be given in drachm doses 
stirred into a small cup of hot water at bedtime, is of 
ancient repute, and the same may be said of full doses 
of camphor. 

Not much can be said in favor of cold douches 
to the perineum, which would be likely to aggravate 
the trouble. 

The patient should sleep on a hard mattress, not 
on feathers, and should accustom himself to sleep with 
very few bedclothes over him. 



— 77 — 
The utility of avoiding romances of a certain 
character as well as everything else that can stimu- 
late the sexual passion (and under this head come 
tobacco and alcohol) is sufficiently obvious. 

INSOMNIA OF TOXIC ORIGIN. 

The natural effect of alcohol on the cerebral 
functions is to impair healthful sleep. It excites the 
cerebrum by increasing the heart's action and the 
blood-flow, and by directly stimulating the cortical 
cells concerned in conscious activity. This is the 
ordinary action of alcohol when taken moderately, 
the effects of liquors being, as a rule, the less baneful 
the less impurities they contain, and the nearer they 
approach by rectification or by age to the type of 
pure ethyl alcohol. 

It is possible that the stimulant effect of the alco- 
hol on the stomach, rendering that organ hyperaemic, 
may sometimes promote sleep by temporarily ansemi- 
ating the brain. On the whole, however, alcohol is a 
most unsatisfactory hypnotic, and the sleep which 
attends its ingestion is generally brief, and followed 
by a period of wakefulness later on. 

It is by no means proved that alcohol in any 
form ever fulfils the prime requisite of a hypnotic, 
that of lessening the amount of blood in the brain. 
The stupor which follows small medicinal doses is 
regarded by many authorities as a minor degree of 
that narcosis which comes on after excess. Into this 



- 78 - 
narcotism enter as factors the toxic effects of the 
alcohol on the cerebrum, vaso-motor paresis, and the 
paralyzing action of blood poisoned by carbonic acid, 
whose retention is due to interference with the respi- 
ratory function. Jaillet, moreover, has shown that 
the blood globule, when impregnated with alcohol, 
loses the property of transforming all its haemoglobin 
into oxyhemoglobin; for the oxygen of respiration 
unites at the same time with the alcohol and the 
haemoglobin of the corpuscles; in other words, the 
alcoholized blood becomes too poor in oxygen to pro- 
perly subserve either the nutrition or function of the 
cerebral cells. These considerations show how com- 
plex is the action of alcohol on the brain, and the 
necessity of caution in prescribing it in derangements 
of sleep. Certainly the continued use of alcoholic 
stimulants, even in moderate doses, for hypnotic 
effect, is likely to defeat the purpose for which the 
remedy is given, by producing in the end a very ob- 
stinate insomnia, if we can trust some recent authori- 
ties; and this it does by inducing a permanent loss of 
tone in the cerebral blood-vessels, if not by favoring 
arteriosclerosis. " The effect of alcohol on the 
brain," says B. W. Richardson, " is to produce and 
maintain the relaxation of its vessels, to keep them 
charged with blood, and so hold back the natural 
repose. Under this^ divergence from natural life, the 
sleepless man lies struggling with unruly and uncon- 
nected trains of thought. . . . The more he tries, 



— 79 — 

the less he succeeds, till the morning dawns." Rich- 
ardson affirms that arterial atheroma is a frequent 
consequence of even moderate indulgence in alcoholic 
beverages, and doubtless there is much testimony in 
support of this contention. As for the effects of long 
•continued intemperance, there is no doubt that this is 
one of the most prolific sources of arterial degenera- 
tion. Nor is even beer exempt from harm of the same 
kind, and there is warrant for the belief that "the use of 
b>eer in many instances produces a species of degener- 
ation of all the organs, profound and deceptive fatty 
deposits, diminished circulation, conditions of conges- 
tion and perversion of functional activities; local in- 
flammations of both liver and kidneys are always 
present." Intellectually, a stupor amounting almost 
to paralysis arrests the reason, changing all the higher 
faculties into a mere animalism, sensual, selfish, slug- 
gish, varied only with paroxysms of anger that are 
senseless and brutal. A writer in the Scientific Amer- 
ican, who makes this assertion, claims a wide observa- 
tion of the effects of beer-drinking among the various 
civilized nations. 

But the point which we wish here to emphasize 
is, that the moderate use of alcohol in any form may 
produce insomnia by its exciting action on the heart 
-and circulation, and on the cerebral cells; that the use 
of it as a hypnotic may, in the long run, defeat the 
end for which it is given; and that prolonged, immod- 
erate indulgence, even in the milder intoxicant bever- 



ages, may produce grave cerebral disturbances and 
such as are incompatible with healthful sleep. 

The remedy for alcoholic insomnia is that of al- 
coholism in general — the most complete abstinence 
from the toxic cause. Prolonged mental rest, the 
natural vaso-motor tonics, out-door air, massage, in- 
vigorating exercise, cold bathing, and perhaps sea- 
bathing, are indicated, and a nutritious diet adapted 
to the enfeebled state of the digestive organs. These 
patients are often benefited by a prolonged course of 
strychnia. One-thirtieth of a grain may be given 
three times a day, or ten drops tincture of nux vom- 
ica, just before meals. Hypnotics will be temporarily 
needed — chloral or paraldehyd. The combination of 
twenty grains of chloral with twenty drops of tincture 
of capsicum, in two fluid ounces of chloroform water r 
is a good one. 

Physicians are seldom called upon to treat insom- 
nia due to tea-drinking or coffee-drinking. The num- 
ber of those who abuse these beverages is probably 
small, and the congenitally feeble and neuropathic 
early learn by experience to indulge sparingly in 
them. The tea-drinking malady is characterized by 
" sleeplessness, or sleep disturbed by dreams or night- 
mare, headache, irritability of temper, depression, 
hypochondriasis, disorders of special senses, auditory 
and visual disturbances, neurosal palpitation, dyspep- 
sia, intestinal torpor (with the accompanying flatu- 
lence and constipation), neuralgia, muscular enfeeble- 
ment and tremor." (Macfarlane.) 



Insomnia is a frequent consequence of excesses 
in the use of tobacco. This is brought about, partly, 
by the digestive and circulatory troubles which char- 
acterize chronic nicotinism. 

But the nervous centres are most violently smit- 
ten, especially the medulla oblongata, whence the car- 
diac, circulatory, and respiratory disturbances. The 
direct excitant influence of nicotine on the cortical 
centres is considerable; the existence of vaso-motor 
paresis is undoubted. 

Entire abstinence is the only remedy; the poison 
is quickly eliminated. It has been found that the 
wakefulness is lessened by four-gramme doses of 
monobromide of camphor at night (Macfarlane), but 
any of the milder hypnotics may be administered. 

The only other toxic agent necessary to allude to 
is opium. Opium and morphine may almost be said 
not to deserve a place among true hypnotics, so little 
do they bring about the conditions of normal sleep. 
It is known that they render the cerebrum hypersemic; 
they paralyze the vaso-motors, and act upon the 
nerves which supply the respiratory muscles so as to 
interfere with the process of respiration (W. A. Ham- 
mond) ; hence the sleep which results from their use 
is more like stupor than natural sleep. 

A most obstinate and unmanageable insomnia 
attends the opium or morphine habit, for the cure of 
which special treatment is necessary (especially in 
aggravated cases), and, generally, isolation in an insti- 



tution possessed of properly trained nurses, and 
where restraint can be exercised. 

The literature of morphinism is now quite exten- 
sive; prominent among works devoted to this subject 
are two treatises lately published, one by Regnier, the 
other by Oscar Jennings. 

In breaking off the habit, Jennings declares in 
favor of the gradual method; and in conjunction with 
Professor Ball he has made some careful experiments 
on the power of sparteine and nitro-glycerin to com- 
bat the circulatory disturbances which attend the 
period of amorphinism. 

INSOMNIA OF CONTINUED FEVERS AND ITS TREAT- 
MENT. 

In typhus and typhoid fever, sleeplessness is a 
frequent, troublesome, and often dangerous symptom. 
Dr. Murchison, writing of the necessity of sleep in 
typhus, says: "The practitioner cannot be too forci- 
bly impressed with the fact that loss of sleep at any 
stage of typhus, if it continue for two or three nights, 
is of itself sufficient to kill." 

In typhoid the necessity of sleep is no less ur- 
gent. One of the first symptoms of approaching dis- 
solution is a restlessness which forbids sleep, and the 
return of refreshing sleep is hailed by physicians and 
attendants as a presage of recovery. 

In the earlier stages of these fevers, insomnia is 
pretty certain to accompany the hyperthermia, while 



- S3 - 

sleep often attends a fall in the temperature. It 
would seem that over-heated blood is itself inimical 
to sleep by exciting the cerebrum. Certain it is that 
cold bathing — the cold or tepid bath — and anti- 
pyretics that bring down the fever quiet the nervous 
disturbances and promote sleep. Hence, for the rest- 
lessness and insomnia of typhus and typhoid fevers, 
there is often no better treatment than a cold bath of 
about fifteen minutes' duration, the temperature of 
the water being from 6o° to 75 ° F., and during the 
bath cold water may be poured on the head in cases 
of extreme pyrexia with restlessness and delirium. 
While fifteen minutes ought to be long enough to de- 
press the febrile heat to nearly the normal, in some 
cases the bath may be of longer duration. "The 
earlier the stage, the higher the fever, the more 
robust the constitution, the colder should the water 
be. The later the stage, the weaker the constitution, 
the more affected the nervous system, the warmer 
should be the water." * 

Some writers claim to have found cold sponging 
and the wet-pack a sufficient substitute for the cold 
bath. Others have derived only a temporary refresh- 
ing from these milder means. 

Where the cold bath is impracticable, from diffi- 
culties on the part of the patient or his surroundings, 
some one of the new antipyretics may be tried. There 



■J. C. Wilson. 



— 8 4 — 

is much testimony in favor of acetanilid as a nervous 
sedative in fevers. Five grains every hour for three 
or four doses (in an adult) will generally lower the 
febrile temperature two or three degrees, and one 
or two hours of quiet sleep (especially if the medicine 
be given in the night-time) is almost certain to follow. 
By many practitioners and hospital physicians, anal- 
gesin is regarded as the preferable hypnotic; the dose 
should be double that of acetanilid. 

These antipyretics, though they undoubtedly 
have a marked action on the thermogenetic and 
thermotaxic heat-centres, which are under abnormal 
irritation by the fever-poison, an action which is ex- 
tended to the higher cerebral centres, certainly do not 
affect the infectious agent, and hence the course of 
the fever is not influenced by them. Their prolonged 
use is probably attended by some cardiac depression 
(an evil to be especially shunned in fevers), and the 
best clinical authorities are shy of them, seeing no 
permanent advantage in the continued administra- 
tion of these medicaments, but possibly mischief. At 
the most, their employment is restricted to the obten- 
tion of such sedation as is needed for the nervous dis- 
turbances. 

Among the pure hypnotics, chloral still deservedly 
takes the lead in the treatment of the insomnia of 
fevers. It calms the delirium, saves the forces, mod- 
erates the fever, and produces a sleep strikingly like 
natural sleep in its refreshing effects (Liebreich, 



- 8 5 - 

Nothnagel, Flint, Russell, Dujardin-Beaumetz). The 
■only contra-indication is cardiac weakness. In the 
latter stages of typhus and typhoid it is better to 
avoid chloral, substituting opium or morphine, and in 
the earlier stages, where there is much jactitation and 
delirium, and especially when diarrhoea is a prominent 
symptom, 20 drops at bedtime of the deodorized tinc- 
ture of opium in a little camphor-water is a useful 
adjunct to other measures intended to subdue rest- 
lessness and produce sleep. 

With regard to sulphonal, we think that experi- 
ence has proved this hypnotic to be of little utility in 
the obstinate insomnia of fevers, and the same may 
be said of chloralamid and other of the more recent 
hypnotics. Paraldehyd, were the taste not so ob- 
jectionable, might render considerable service in the 
delirious insomnia of typhus. 

Alcoholic stimulants judiciously administered 
sustain the heart and circulation, promote the nutri- 
tion and restoration of the nervous system, and thus 
come under the head of remedies useful to combat 
insomnia. Given in too large or too frequent doses, 
they undoubtedly defeat the end for which they are 
given, and aggravate existing nervous disturbances. 
There is another reservation, — they must be cautiously 
prescribed where there is renal insufficiency. 

Stokes, in his lectures, speaks of the well-marked 
calming and sedative effect of wine in fever. " A pa- 
tient who has been restless, sleepless, and delirious 



— 86 — 

will sometimes become quiet and fall asleep after the 
administration of a little wine. This occurs where 
the nervous symptoms are probably due to an anaemic 
or spanaemic condition of the brain associated with a 
weak heart and a flagging circulation."* 

Febrile insomnia is essentially a toxic insomnia; 
this has been made apparent by the investigations of 
the last few years. Whether it be the microbes or 
their ptomaines, or both, which excite the cerebrum 
and derange the nervous functions, has not been yet 
positively determined. Uraemia probably enters as 
an important factor; in the active stages of fevers, 
and in the declining stages when the circulation is 
oppressed and languid, and the prognosis is grave, 
elimination by the kidneys is always imperfect. 
Hence an important part of the treatment should be 
to promote the excretion of the poison and the re- 
moval of effete matters. Unfortunately, this indica- 
tion can be but imperfectly met. All that can be 
done is by suitable nutrients and stimulants to sustain 
the organic forces in their struggle with the foe, and 
to favor elimination by the kidneys and other emunc- 
tories. The various diluents (lemonade, barley-water, 
effervescent drinks, plain water, etc.) which are so 
freely given, because so constantly craved, promote 
excretion by the kidneys. Milk is often prescribed 
ad libitum as the sole drink and nourishment; its di- 



* "Lectures on Fever," Lea Brothers & Co., 1876. 



- 8 7 - 

uretic properties are well known. Some clinical 
authorities are in the habit of ordering mild diuretic 
mixtures (solutions of nitrate of potassium, of sweet 
spirits of nitre, with sometimes the addition for 
several successive days of a little digitalis) all through 
the fever, and claim good results. 

The bowels should be kept open, suitable mild 
laxatives being given if there be constipation, and fre- 
quent cold or tepid ablutions, followed by brisk rub- 
bing, will do something towards promoting the func- 
tions of the skin. 

We have hinted at anaemia and spanaemia as be- 
ing part causes of the insomnia of continued fevers. 
Emphasize as we may the poisoned condition of the 
blood and the abnormalities of the circulation, the 
fundamental factor in the insomnia, headache, jactita- 
tion, delirium, and hebetude of continued fever is 
malnutrition of the highest nerve-centres, and against 
this our therapeutic resources are meagre. The 
necessity of nourishment is apparent; but little food, 
however, can be assimilated; and, in the absence of 
any specific medication (for which the profession is 
looking), the best that can be done is judiciously to 
combat dangerous symptoms The insomnia is the 
measure of the cerebral disturbance, and, if this can 
be successfully overcome, one important obstacle at 
least in the way of recovery is removed. 

********* 

[Chapters on syphilis, rheumatism, gout, and lith- 



cemia, as producers of insomnia, were originally drafted, 
but it was found impossible to include them without mak- 
ing this volume too bulky. A treatise on all the causes of 
the derangements of sleep would comprehend almost the 
whole of internal, and even surgical pathology '.] 



CHAPTER III. 

HYPNOTICS. 

The limits of this treatise will allow of only a 
brief consideration of the leading agents that properly 
come under this head. I shall take up first the med- 
icinal hypnotics, then the remedial agents not med- 
icinal. 

I. OPIUM AND NARCOTICS. 

Opium is the most ancient and still the most 
universally employed hypnotic. The narcotic prop- 
erty of opium is the result of its morphine, codeine, 
papavarine, and cryptopine — all somniferous alkaloids. 
Opium is far from being a pure hypnotic; in small 
doses its action is that of an excitant of the cerebrum, 
and generally it is only in tolerably large doses that 
it is hypnotic. Many persons find opium, and espe- 
cially morphine, powerful promoters of wakefulness, 
sleep only following many hours after the ingestion 
of the narcotic. 

Opium is par excellence the hypnotic where the 
insomnia is due to pain. Opium undoubtedly exerts 
its power by a stupefying action on the cortical cells, 
rather than by any changes which it effects in the 
circulation. , " It is the peculiar virtue of narcotics," 
says Stille, " to blunt the senses and steep the mind 
in forgetfulness, in spite of pain, of nervous irritabil- 
ity, or of tormenting thoughts." 



_ 9 o — 

The combination of opium or morphine with the 
pure hypnotics, as chloral, sulphonal, paraldehyd, 
urethan, is often highly efficacious. The following 
formulse are recommended: (These prescriptions 
are designed for adults only.) 

CHLORAL AND MORPHIA. 

5 Morphinae sulph gr. ij. 

Hyd. chloral 3 ij. 

Syrup tolu § ij. 

M. Sig. — A teaspoonful when needed to induce sleep. 

PARALDEHYD AND TINCTURE OF OPIUM. 

5 Paraldehyd 3 i. 

Tinct. opii deod gtt. xx. 

M. For one dose. To be taken in a little old rum and 
water. Valuable in the insomnia of melancholia, in deli- 
rium tremens, incipient paralytic dementia, etc. 

.SULPHONAL AND MORPHIA. 

B Sulphonal 3 ss . 

Morph. sulph gr. %. 

M. One powder, for a hypnotic effect where there is 
great nervous irritability or pain. 

MORPHINE WITH CHLORAL AND BROMIDE OF SODIUM- 

(From Macfarlane.) 

5 Liqui morphin acet f 3 i - 

Hyd . chloral 3 i • 

Bromid . sodii 3 ij • 

Syrup tolu 3 iv . 

Aquam add §iv. 

M. Sig. — Take one-fourth part in water before bedtime, 
and repeat in two hours if required. 



Other narcotics— belladonna, hyoscyamus, Indian 
hemp, stramonium — have but feeble hypnotic power. 
They are not absolutely devoid of this power, as some 
writers have affirmed, but they are not to be depended 
on. 

In insomnia due to genital irritation (such cases 
as sometimes come before the notice of the physician 
in connection with habits of masturbation and at- 
tempts at reformation, or in continent young men 
who are kept awake by troublesome erections), also 
in the insomnia produced by gonorrhceal chordee, 
hyoscyamus is often of real efficacy. The camphor 
and hyoscyamus pill is £ convenient formula: 

9 Pulv. camph gr. i. 

Ext. hyoscyam gr. iij. 

M. For one pill. To be taken at bedtime. A supposi- 
tory of ext. hyoscyamus, 3 grains, and pulv. opii 1 grain, 
with cacao butter, may be often used to advantage. 

In chordee, I have given teaspoonful doses of 
tincture of hyoscyamus three times a day without 
producing any troublesome dryness of the mouth and 
throat or dilatation of the pupils, and seen quiescence 
and sleep follow. 

Lettuce and hops possess true hypnotic virtues, 
with mildly stupefying properties, and do not produce 
any arterial or cerebral excitement or delirium, or any 
subsequent paralysis of nervous or muscular function 
like other narcotic agents, and particularly opium and 
belladonna; they act in this respect more like chloral 



— 9 2 — 

and paraldehyd than like opium, engendering a calm 
which soon passes into natural sleep. 

I know certain aged patients who sleep poorly in 
consequence of cerebral arterial degeneration, but 
who affirm that when they are able to indulge freely 
in lettuce as an article of diet, they sleep very well. 
I have not, however, seen the least hypnotic benefit 
from any pharmaceutical preparation said to contain 
lettuce. 

HOPS-LUPULIN. 

I have known simple insomnia from neurasthenia, 
from care, worry, overwork, etc., temporarily relieved 
by teaspoonful doses of lupulin on retiring. I say 
temporarily, for I have never known the effect to last 
longer than two or three nights. The doses must be 
rather large. Hop tea can be of little use, as hops 
do not yield their active principle to water. Lupulin 
is a yellow powder formed on the surface of the scales 
of hops; it is obtained by rubbing or threshing or 
sifting the strobiles, of which it constitutes from one- 
sixth to one-tenth by weight. It contains a volatile 
oil and bitter principle which are readily soluble in 
alcohol. Lupulin may be given in pill form, or be 
taken in the form of a paste, mixed with water or 
syrup. 

Doubtless in cases of insomnia from irritable 
bladder, and from genital irritation, nearly all practi- 
tioners have occasionally found lupulin in teaspoonful 
doses useful. 



— 93 — 
It will not do in closing this topic to omit to men- 
tion the hop pillow, which has sometimes proved 
beneficial in allaying restlessness and producing sleep 
in nervous disorders. The pillow should be moistened 
with spirits before being placed under the head of the 
patient (Dr. Geo. B. Wood). 

Pills for Satyriasis {Dujardin-Beaumetz). 

Lupulin 2 grammes. 

Bromide potassium 2 grammes. 

Ext. nymphoea (water lily), q. s. 
For 20 pills. Sig. Take two pills every two hours. 

II. ALCOHOL, AND OTHER STIMULANTS —EUPEPTIC 

AGENTS. 

Alcohol sometimes acts as a hypnotic, and is in 
fact frequently resorted to for that purpose. It pro- 
duces sleep, not because it is a vascular stimulant, 
clearing the over distended blood-vessels, but because 
it is taken in a sufficient dose to have a narcotic effect. 
Ale is especially chosen for hypnotic effect; the hops 
with which it is impregnated undoubtedly aid the calm- 
ative action. Whiskey or brandy to have a soporific 
effect should be of pure quality, and the older the 
better. The theory that liquors long mellowing in the 
cask get rid of fusel oil and other alcohols not ethylic, 
and develop soothing ethers, seems actually sustained 
by facts; certain it is, moreover, that new liquors 
adulterated with the higher atomic and more fiery 
alcohols are excitant, and therefore antagonistic of 



— 94 — 
sleep. A tablespoonful or two of pure whiskey taken 
on going to bed will often relieve the insomnia of the 
exhausted, the irritable, the nervous; the insomnia 
due to mental overwork or worry will often promptly 
yield to the alcoholic potion. It is well to administer 
the spirit in a tumbler of hot water — as hot as can be 
drunk — as the heat favorably excites the stomach, and 
through that organ reflexly soothes and inhibits the 
cerebrum. 

Unfortunately, the sleep produced by alcohol is often 
of short duration; the patient awakes after a couple of 
hours but little refreshed, and may lie awake much of 
the night without being able to go to sleep again. 
The combination of whiskey with a little sulphonal 
may, however, remedy this. The sulphonal may first 
be taken in fine powder, well stirred, till it is about 
the thickness of cream, into a little water; this is fol- 
lowed by the draught of whiskey. When the effects 
of the alcohol begin to subside, those of the sulphonal 
(which is slow to undergo absorption) are just com- 
mencing. I have known a dose of only 10 grains of 
sulphonal, followed by a tablespoonful of old whiskey 
in a little hot sweetened water, to oe succeeded by 
eight hours of sound sleep. 

Ginger, peppermint, camphor, lavender, carda- 
mom, and other gastro-intestinal stimulants and 
'''carminatives," taken with hot water, occasionally 
prove hypnotic. Even hot water alone may induce 
sleep if drunk freely on going to bed; in such cases 



— 95 — 
it may be supposed that the insomnia is the result of 
a dyspeptic state, and that the increased vasculariza- 
tion of the stomach may cause diminished vasculariz- 
ation of the brain, thus producing one of the condi- 
tions of sleep. A few drops of the aromatic spirits of 
ammonia, of the ammoniated tincture of valerian, of 
the fluid extract of skullcap, will sometimes enable 
the individual speedily to pass the barrier which sep- 
arates the waking from the sleeping state. Many a 
person rendered sleepless by a disordered stomach — 
the seat of acrid fermentations — has been enabled to 
realize immediate quiescence of both stomach and 
brain by a dose of rhubarb and soda, a drachm of 
Carlsbad salt in a cup of hot water, or even the same 
quantity of bicarbonate of sodium taken in the same 
way. 

III. BROMIDE OF POTASSIUM AND BROMIDES. 

Among the newer hypnotics must be mentioned 
bromide of potassium, which still has a great reputa- 
tion as £ remedy for chronic insomnia. It probably 
produces its effects, as Vulpian taught, not by angemi- 
ating the cortex,* but by the influence which it directly 
exerts on the anatomical elements. " It simply less- 
ens the functional activity of the brain, without dis- 
turbing the relation of one part to another" (Brunton). 
Where the indication is to diminish cerebral or spinal 
irritability; where the brain is hyperaemic from excess 



*Le(ons sur les Vaso-moteurs, t. ii, chap. 



- 9 6- 

of mental toil, from prolonged watching, from abuse 
of stimulants; in nervous erethism characterized by 
emotional excitability, exaggeration of the reflex 
activity; in the insomnia of fevers, and in genito- 
urinary insomnia, bromide of potassium (at least till 
the discovery of chloral) has been the best hypnotic 
known to the profession. It depresses innervation 
generally, and is a debilitant of the heart; hence, in 
the feeble, asthenic, and cardiac, it is to be prescribed 
with caution. It may often with advantage be asso- 
ciated with chloral and morphine; if given with 
whiskey its depressant action is less marked; the com- 
bination with calisaya, with simple elixir, with anise 
cordial, makes it often more acceptable to the stomach. 

I£ Pot. brom grs. xxx. 

Anise cordial § i. 

M. For one dose. 

B Pot. bromid § ss. 

Elix. calisaya, ) .... „ ... 

c , ■ \ aa 1 U J- 

Sherry wine, ) 

M. Sig.: A teaspoonful three times a day and at bed- 
time. 

1J Pot. bromid., ) .. 

Hyd. chloral, j 

Tinct. valerian 3 vi. 

Spts. lavend. co 3 vi. 

Aquae camph q. s. ad § vi. 

M. Sig.: A tablespoonful every two hours till sleep i& 
induced. 

The above formula has been of great use to me 
in the treatment of alcoholic insomnia. 



— 97 — 

BROMIDE OF LITHIUM. 

The bromide of lithium, according to Macf ar- 
lane, is the best hypnotic of the bromide salts, as it 
contains a half more bromine than the potassium bro- 
mide. Its dose is 10 to 20 grammes. Macfarlane 
recommends the combination with ergot of rye and 
digitalis, both of which are stimulants of the vaso- 
motor centres. 

IJ Bromidi lithii grs. xl. 

Fluid ext. ergot 3 i. 

Tinct. digitalis nj, xx. 

Chloroform water 3 xv. 

M. Sig. : Take one-half two hours before going to 
bed, and the other half at bed-time.* 

IV. CHLORAL. 

The discovery by Liebreich, in 1869, of the hyp- 
notic properties of hydrate of chloral may be regarded 
as one of the most important therapeutic discoveries of 
modern times. The experience of the past twenty-two 
years has more than justified the first conclusions 
respecting its actions and uses, and chloral may still 
be regarded as, on the / whole, the best hypnotic we 
possess. Its principal advantages are: 1. It is speedy 
and generally certain in its action. 2. There is no 
preliminary period of excitement. 3. Its effects are 
prolonged, and the sleep which it produces is calm, 
tranquil, and refreshing; the patient wakes out of the 

* Insomnia and Its Therapeutics, p. 88. 

7 BBB 



chloral sleep as out of natural sleep. 4. It can be 
given with good results in cases where opium is not 
tolerated. 5. There are seldom any unpleasant or in- 
jurious after-effects; it does not disturb the secretions 
or excretions, as do many other hypnotics. 6. It has 
a wide range of usefulness besides being simply a 
sleep-producer; in all morbid cerebro-spinal condi- 
tions attended with excitation, delirium, or spasm, it 
is markedly beneficial; in the insomnia due to delirium 
tremens, acute mania, general paralysis of the insane, 
puerperal mania, chorea, tetanus, etc., it is of great 
value. 

Among its disadvantages are: 1. It is a cardiac 
depressant, and therefore must be given with great 
caution, or withheld in organic affections of the heart. 
2. It is a dangerous remedy when long-continued, its 
effects on the brain, and consequently on the mental 
functions and disposition, being deplorable. The 
chloral habit is, doubtless, quite as bad as the morphine 
habit. "Its employment," says Macfarlane, "is so 
fraught with risk that its use, except under medical 
advice, is much to be deprecated. 

" At first the mental depression and melancholia, 
from which the patient suffers, are alleviated by a 
dose of the drug; after a time it fails to soothe, and 
may even excite. The victim gravitates into a pitia- 
ble state of mental weakness and demoralization, be- 
coming childish, vacillating and untruthful, some- 
times dejected, at other times excited, and having 



— 107 — 

and almost everybody has experienced the difficulty 
of going to sleep when the feet are cold.* 

The Wet Pack. — This is a very active hydro- 
therapy method, being a " derivative or calmative 
of the highest order" (Macfarlane).f A sheet is 
wrung out of cold water, and the patient is enveloped 
in it from neck to ankles, the head and feet not being 
included. Several dry blankets are wrapped around 
the patient, a hot water bag is applied to the feet, a 
cold wet cloth to the forehead, and the patient is 
allowed to remain in the pack from half an hour to 
an hour. At the end of the process he is rubbed 
down with dry cloths to promote vigorous reaction. 

The Turkish Bath. — The Turkish bath is highly 
recommended in many cases of insomnia. It relieves 
cerebral congestion, and promotes circulation and 



* Hammond employed with success, in a young girl 
whose extremities were habitually cold, electrization of the 
sciatic nerve. 

f Experiments of Weir Mitchell have shown that the 
effect of chilling the cerebrum is a brief sedative action. 
Then phenomena of motor excitation are developed, sensi- 
bility is lessened, and if the application of cold is continued, 
the animal falls into a profound stupor, and surgical opera- 
tions may be performed on him without the least movement. 
When cold is applied to the medulla oblongata, the respira- 
tory movements are first tumultuous, then they are slowed, 
and finally cease altogether. (Quoted from " Clinical Thera- 
peutics," by Dujardin-Beaumetz. Published by G. S. Davis, 
Detroit, Mich.) 



— 108 — 

arterial tone, as well as digestion and assimilation. 
The Turkish bath consists of three rooms. The tem- 
perature of the first, or dressing room, is moderate, 
that of the second is higher, that of the third is higher 
still. In the first room, the bather, after dressing, 
winds one towel around his loins and a second 
around his head in the form of a turban. If he has any 
tendency to cerebral congestion, the second one may 
be wet. He then passes into the second room, where 
he waits a short time before passing into the third 
room. Some people, however, go directly into the third 
room. In both the second and third rooms the bathers 
partake freely of cold water. A few minutes' stay in 
the warmest room is usually sufficient to make the 
bather perspire freely, and he then returns to the 
second or cooler room, where he may remain half an 
hour or more, according to circumstances. He may 
then be shampooed, the surface of the body being 
rubbed, the muscles kneaded, and the smaller joints 
extended. He is then washed with a lather of soap, 
and sluiced with basins of tepid or warm water. For 
some people it is most agreeable after this to be 
simply wrapped in warm towels and allowed to repose 
in the dressing-room. Others prefer to finish up with 
a cold douche before proceeding to the dressing-room. 
Here they remain resting for a considerable time be- 
fore they again dress.* 



Brunton's Pharmacology and Materia Medica. 



— 109 — 

Hot Compresses, consisting of layers of flannels 
wrung out of hot water and covered with dry flannels, 
are sometimes of benefit in insomnia when applied 
over the abdomen. 

In an interesting lecture recently published in 
the Dietetic Gazette (Dec, 1891), Dr. C. L. Dana, in 
speaking of the benefits of hydrotherapy in nervous 
diseases, regards the wet pack as a most useful seda- 
tive in neurasthenia and insomnia, and a good sub- 
stitute for medicinal sedatives, like the bromides. It 
should be given three or four times weekly, or for a 
short time daily. The tepid bath ranks next in its 
sedative efficacy. The shower and jet baths are a 
most valuable means for securing tonic effects. 

In weak, sensitive and anaemic women, he pre- 
scribes, first, dry hot packs for a week, then wet packs, 
and, finally, the drip sheet or cool shower. The 
Turkish bath and the hot Sitz bath (the patient sitting 
for twenty to thirty minutes in water at blood heat) 
have also been found to have excellent sedative 
effects and to be promotive of sleep. 

Electricity. — My experience, like that of most 
general practitioners, has been confined to faradism. 
I have resorted to this form of electricity for the re- 
lief of obstinate insomnia. I have never applied the 
current to the head, but have sought to obtain a 
powerful derivative effect by applications of the wet 
sponge, or the metallic brush, to distant parts of the 
body. I have seen neurasthenic patients quieted and 



made able to sleep by faradization up and down the 
spine about bed-time; also by a general electric mass- 
age, given with the hand, which is made to communi- 
cate the current. 

Stille (Therapeutics and Materia Medica) speaks 
of obtaining success " by passing a fine secondary or 
primary current from the cervical vertebrae to the 
epigastrium, and from the dorsal vertebrae to the en- 
tire front of the chest." " Drowsiness," he adds, "is 
not uncommon in anaemic and debilitated persons 
during the use of a generally applied direct inductive 
current. It has occurred only under the influence of 
a fine interrupted current of the second order, with a 
low intensity. In old persons who are restPess and 
sleep badly, a current of this kind passed over the 
forehead, while the negative is carried over the shoul- 
#ers and down the arms, quickly promotes sound and 
prolonged sleep." 

Doubtless cutaneous faradization produces that 
anaemic condition of the encephalon which is favora- 
ble to sleep; in confirmation of the view that this is 
the case, we have the observation of Nothnagel that 
" cutaneous electrical stimulation is followed by a re- 
flex contraction of the vessels of the pia mater." 

Central galvanization has proved efficacious in 
the experience of Berdet, Meyer, Erb, Skene, Keith, 
Macfarlane, and others. According to the experi- 
ments of Legros and Onimus, currents of descending 
direction (positive pole over the forehead, negative 



pole to the neck) determine contraction of the vessels 
of the pia mater; reverse the poles, and a directly 
contrary effect is obtained. 

Doubtless electro-therapeutists, by their ready 
control (through the proper currents) of the vaso- 
motors, are able to modify the intra-cranial circula- 
tion at will, and if sleep were only a circulatory phe- 
nomenon, they would be able to give us infallible 
recipes for all kinds of insomnia. Unfortunately the 
laws of natural sleep are not exactly the same as the 
laws of the vaso-motors: sleep is, as has before been 
said, something more than a plus or minus of blood 
in the brain. If galvanism is a remedy for insomnia, 
it is by improving the tone of the vessels, and the 
nutrition of the cerebral cells, rather than by any 
transient influence on the circulation, that it does 
good. 

The subject is one on which a long chapter 
might be written, but such a chapter would be inap- 
propriate for this treatise. The successful treatment 
of insomnia by galvanism presupposes, on the part of 
the practitioner, a knowledge of technical details and 
a skill which can only be acquired by a study of the 
best special treatises on electro-therapeutics and by 
long practice. Moreover, the range of usefulness of 
electricity in insomnia is largely limited to neuro- 
pathic or neurasthenic cases. 

Lewandowski and Eulenburg state that they 
have obtained very favorable results with franklini- 



zation. The head plate is used, and the electricity is 
conveyed in the form of breez)' currents which are 
both agreeable aud soothing to the patient. By 
means of the discharging hand electrode, the patient 
is also electrified through his clothes; the seances last 
about half an hour, and the patient goes to bed 
soothed and ready to go to sleep. At the Adams 
Nervine, Jamaica Plain, much account is made of 
static electricity in the treatment of nervous insomnia, 
and my friend Dr. B. W. Bartlett, of Rowley, informs 
me that he relies principally on this form of electric- 
ity (along with other hygienic means) in the treatment 
of neurasthenia and its accidents, insomnia included. 

To conclude the chapter on Hypnotics — if drugs 
have had the greatest prominence among the thera- 
peutic means, it is not because they are really the 
most important. I think that physicians should be 
very chary in prescribing the medicinal hypnotics. We 
still know too little about their action on the delicate 
cells of the brain and on the vaso-motors. Many of 
them, by constant or frequent use, become positively 
baneful. It is, therefore, with a caution against the 
careless employment of hypnotics that I close this 
book, and with an exhortation to physicians first to 
try fully (when possible) all available hygienic 
resources before resorting to medicinal hypnotics. 



INSOMNIA. 



SLEEP, poetically expressed, is " Life's nurse sent from 
Heaven to create us anew from day to day." It is, in- 
deed, " Tired Nature's sweet restorer." 

Insomnia may be dependent upon derangement of the 
nervous, circulatory, respiratory or urinary organs, the alimen- 
tary tract, the liver, or upon febrile or general disease. It 
may also be caused by unhygienic conditions of heating, light- 
ing, ventilation, diet, or occupation. 

Whatever its cause, which must be sought for, and as far 
as possible removed, resort must often be had to medicinal 
agents. 

Preparations of the Bromides, Chloral, Gelsemium, Opium 
and Henbane are most universal y employed. 

We supply these in combination in two different formula, 
under the name of 

CEREBRAL SEDATIVE COMPOUND 

(Formula A, with Opium; Formula B, with Henbane substi- 
tuted for Opium, the latter for cases in which Opium is contra- 
indicated). 

The following prescription is an eligible one for admin- 
istration: 

5 Cerebral Sedative Compound, 

Syr. Sarsaparilla Compound, aa § iv. 
p., D. & co.'s. , 
Sig. : Dessertspoonful when indicated. 

Descriptive literature of our products sent to physicians 
on request. 

PARKE, DAVIS & COMPANY, 

DETROIT AND NEW YORK. 



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Electricity, Its Application in Medicine. 

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